EnrollEligCOB
Class PriorAuthorization

Prior authorization is a requirement that a prescribing physician obtain approval from the patient's health plan to prescribe a specific medication. Without this prior approval, the patient's health plan may not provide coverage, or pay for, the medication. This class contains information concerning a prior authorization already issued by a payer so that (among other reasons) the pharmacy would be aware of the prior authorization and may cite the prior authorization details to the payer on a claim in order to ensure that the payer recognizes the claim as authorized and therefore improves the chances of payment.

Attributes
«CS» Code category category

"Code clarifying the Prior Authorization Number Submitted or benefit/plan exemption." - NCPDP Telecommunication (Field 461-EU, Data Dictionary 201104). Possible values include: Prior Authorization; Medical Certification; Early Periodic Screening Diagnosis Treatment; Exemption from Copay and/or Coinsurance; Exemption from RX; Family Planning Indicator; Temporary Assistance for Needy Families; Payer Defined Exemption; Emergency Preparedness; Not Specified.

«TS» PointInTime dateProcessed dateProcessed

This is the date that the Processor issued or processed the prior authorization. Provided by the Processor to the Pharmacy.
"Date the prior authorization was processed" - NCPDP Telecommunication (Field 498-PR, Data Dictionary 201104).

«IVL_TS» Period effectiveDateRange effectiveDateRange

The time period during which medication which would ordinarily not be covered by the payer may be dispensed under the understanding that the payer will pay for the medication as per the pre-authorization.
"Date the prior authorization became effective" and "Date the prior authorization ends" - NCPDP Telecommunication (Fields 498-PS and 498-PT, Data Dictionary 201104).

«II» Id identifier identifier

Identifies the pre-authorization. This Id is assigned by the Processor.
"Unique number identifying the prior authorization asigned by the processor" - NCPDP Telecommunication (Field 498-PY, Data Dictionary 201104).
"Number submitted by the provider to identify the prior authorization." - NCPDP Telecommunication (Field 462-EV, Data Dictionary 201104).
"Based on the type of insurance, some coverage plans require that an authorization number or code be obtained prior to all non-emergency admissions, and within 48 hours of an emergency admission. Insurance billing would not be permitted without this number. The date and source of authorization are the components of this field." - HL7 Version 2.8, IN1-14.
"Contains the number assigned by the certification agency." - HL7 Version 2.8, IN3-2.

«PQ» Quantity maximumQuantity maximumQuantity

The quantity of medication which would ordinarily not be covered by the payer that may be dispensed under the understanding that the payer will pay for the medication as per the pre-authorization.
"Amount authorized expressed in decimal units." - NCPDP Telecommunication (Field 498-RA, Data Dictionary 201104).

«MO» MonetaryAmount moneyAuthorized moneyAuthorized

The dollar amount authorized for the dispensing of a medication that otherwise would not have been covered by the Payer.
"Amount authorized in the prior authorization." - NCPDP Telecommunication (Field 498-RB, Data Dictionary 201104).

«REAL» Decimal nbrOfRefillsAuthorized nbrOfRefillsAuthorized

"Number of refills authorized by the prior authorization." - NCPDP Telecommunication (Field 498-PW, Data Dictionary 201104).

OrderablePharmacyItem orderablePharmacyItem orderablePharmacyItem

Pointer to the medicinal product that is the subject of the pre-authorization request. Note that this property may seem redundant as the Pharmacy Order contains an ordered item and points to the Prior Authorization class that owns this property. It is not redundant, however, as the pre-authorization may have occurred before the order occurs, and may be for a (slightly) different orderable medication, for example, the prior authorization may have been for a brand name drug, but a generic version is ordered.

«PQ» Quantity quantityAccumulated quantityAccumulated

The amount of medication previously dispensed and paid for under this authorization. Used to determine the quantity remaining for billing under this authorization.
"Accumulated authorized amount expressed in metric decimal units." - NCPDP Telecommunication (Field 498-PX, Data Dictionary 201104).

«CS» Code status status

"The status of the prescription’s prior authorization as known by the sender." - NCPDP Script (Field 7891, Data Dictionary 201104)


Properties:

Alias
Classifier Behavior
Is Abstractfalse
Is Activefalse
Is Leaffalse
Keywords
NamePriorAuthorization
Name Expression
NamespaceEnrollEligCOB
Owned Template Signature
OwnerEnrollEligCOB
Owning Template Parameter
PackageEnrollEligCOB
Qualified NameFHIM::EnrollEligCOB::PriorAuthorization
Representation
Stereotype
Template Parameter
VisibilityPublic

Attribute Details

 category
Public «CS» Code category

"Code clarifying the Prior Authorization Number Submitted or benefit/plan exemption." - NCPDP Telecommunication (Field 461-EU, Data Dictionary 201104). Possible values include: Prior Authorization; Medical Certification; Early Periodic Screening Diagnosis Treatment; Exemption from Copay and/or Coinsurance; Exemption from RX; Family Planning Indicator; Temporary Assistance for Needy Families; Payer Defined Exemption; Emergency Preparedness; Not Specified.

Constraints:
Properties:

AggregationNone
Alias
Association
Association End
ClassPriorAuthorization
Datatype
Default
Default Value
Is Compositefalse
Is Derivedfalse
Is Derived Unionfalse
Is Leaffalse
Is Orderedfalse
Is Read Onlyfalse
Is Staticfalse
Is Uniquetrue
Keywords
Lower1
Lower Value(1)
Multiplicity1
Namecategory
Name Expression
NamespacePriorAuthorization
Opposite
OwnerPriorAuthorization
Owning Association
Owning Template Parameter
Qualified NameFHIM::EnrollEligCOB::PriorAuthorization::category
Stereotype
Template Parameter
Type«CS» Code
Upper1
Upper Value(1)
VisibilityPublic


 dateProcessed
Public «TS» PointInTime dateProcessed

This is the date that the Processor issued or processed the prior authorization. Provided by the Processor to the Pharmacy.
"Date the prior authorization was processed" - NCPDP Telecommunication (Field 498-PR, Data Dictionary 201104).

Constraints:
Properties:

AggregationNone
Alias
Association
Association End
ClassPriorAuthorization
Datatype
Default
Default Value
Is Compositefalse
Is Derivedfalse
Is Derived Unionfalse
Is Leaffalse
Is Orderedfalse
Is Read Onlyfalse
Is Staticfalse
Is Uniquetrue
Keywords
Lower0
Lower Value(0)
Multiplicity0..1
NamedateProcessed
Name Expression
NamespacePriorAuthorization
Opposite
OwnerPriorAuthorization
Owning Association
Owning Template Parameter
Qualified NameFHIM::EnrollEligCOB::PriorAuthorization::dateProcessed
Stereotype
Template Parameter
Type«TS» PointInTime
Upper1
Upper Value(1)
VisibilityPublic


 effectiveDateRange
Public «IVL_TS» Period effectiveDateRange

The time period during which medication which would ordinarily not be covered by the payer may be dispensed under the understanding that the payer will pay for the medication as per the pre-authorization.
"Date the prior authorization became effective" and "Date the prior authorization ends" - NCPDP Telecommunication (Fields 498-PS and 498-PT, Data Dictionary 201104).

Constraints:
Properties:

AggregationNone
Alias
Association
Association End
ClassPriorAuthorization
Datatype
Default
Default Value
Is Compositefalse
Is Derivedfalse
Is Derived Unionfalse
Is Leaffalse
Is Orderedfalse
Is Read Onlyfalse
Is Staticfalse
Is Uniquetrue
Keywords
Lower0
Lower Value(0)
Multiplicity0..1
NameeffectiveDateRange
Name Expression
NamespacePriorAuthorization
Opposite
OwnerPriorAuthorization
Owning Association
Owning Template Parameter
Qualified NameFHIM::EnrollEligCOB::PriorAuthorization::effectiveDateRange
Stereotype
Template Parameter
Type«IVL_TS» Period
Upper1
Upper Value(1)
VisibilityPublic


 identifier
Public «II» Id identifier

Identifies the pre-authorization. This Id is assigned by the Processor.
"Unique number identifying the prior authorization asigned by the processor" - NCPDP Telecommunication (Field 498-PY, Data Dictionary 201104).
"Number submitted by the provider to identify the prior authorization." - NCPDP Telecommunication (Field 462-EV, Data Dictionary 201104).
"Based on the type of insurance, some coverage plans require that an authorization number or code be obtained prior to all non-emergency admissions, and within 48 hours of an emergency admission. Insurance billing would not be permitted without this number. The date and source of authorization are the components of this field." - HL7 Version 2.8, IN1-14.
"Contains the number assigned by the certification agency." - HL7 Version 2.8, IN3-2.

Constraints:
Properties:

AggregationNone
Alias
Association
Association End
ClassPriorAuthorization
Datatype
Default
Default Value
Is Compositefalse
Is Derivedfalse
Is Derived Unionfalse
Is Leaffalse
Is Orderedfalse
Is Read Onlyfalse
Is Staticfalse
Is Uniquetrue
Keywords
Lower1
Lower Value(1)
Multiplicity1
Nameidentifier
Name Expression
NamespacePriorAuthorization
Opposite
OwnerPriorAuthorization
Owning Association
Owning Template Parameter
Qualified NameFHIM::EnrollEligCOB::PriorAuthorization::identifier
Stereotype
Template Parameter
Type«II» Id
Upper1
Upper Value(1)
VisibilityPublic


 maximumQuantity
Public «PQ» Quantity maximumQuantity

The quantity of medication which would ordinarily not be covered by the payer that may be dispensed under the understanding that the payer will pay for the medication as per the pre-authorization.
"Amount authorized expressed in decimal units." - NCPDP Telecommunication (Field 498-RA, Data Dictionary 201104).

Constraints:
Properties:

AggregationNone
Alias
Association
Association End
ClassPriorAuthorization
Datatype
Default
Default Value
Is Compositefalse
Is Derivedfalse
Is Derived Unionfalse
Is Leaffalse
Is Orderedfalse
Is Read Onlyfalse
Is Staticfalse
Is Uniquetrue
Keywords
Lower0
Lower Value(0)
Multiplicity0..1
NamemaximumQuantity
Name Expression
NamespacePriorAuthorization
Opposite
OwnerPriorAuthorization
Owning Association
Owning Template Parameter
Qualified NameFHIM::EnrollEligCOB::PriorAuthorization::maximumQuantity
Stereotype
Template Parameter
Type«PQ» Quantity
Upper1
Upper Value(1)
VisibilityPublic


 moneyAuthorized
Public «MO» MonetaryAmount moneyAuthorized

The dollar amount authorized for the dispensing of a medication that otherwise would not have been covered by the Payer.
"Amount authorized in the prior authorization." - NCPDP Telecommunication (Field 498-RB, Data Dictionary 201104).

Constraints:
Properties:

AggregationNone
Alias
Association
Association End
ClassPriorAuthorization
Datatype
Default
Default Value
Is Compositefalse
Is Derivedfalse
Is Derived Unionfalse
Is Leaffalse
Is Orderedfalse
Is Read Onlyfalse
Is Staticfalse
Is Uniquetrue
Keywords
Lower0
Lower Value(0)
Multiplicity0..1
NamemoneyAuthorized
Name Expression
NamespacePriorAuthorization
Opposite
OwnerPriorAuthorization
Owning Association
Owning Template Parameter
Qualified NameFHIM::EnrollEligCOB::PriorAuthorization::moneyAuthorized
Stereotype
Template Parameter
Type«MO» MonetaryAmount
Upper1
Upper Value(1)
VisibilityPublic


 nbrOfRefillsAuthorized
Public «REAL» Decimal nbrOfRefillsAuthorized

"Number of refills authorized by the prior authorization." - NCPDP Telecommunication (Field 498-PW, Data Dictionary 201104).

Constraints:
Properties:

AggregationNone
Alias
Association
Association End
ClassPriorAuthorization
Datatype
Default
Default Value
Is Compositefalse
Is Derivedfalse
Is Derived Unionfalse
Is Leaffalse
Is Orderedfalse
Is Read Onlyfalse
Is Staticfalse
Is Uniquetrue
Keywords
Lower0
Lower Value(0)
Multiplicity0..1
NamenbrOfRefillsAuthorized
Name Expression
NamespacePriorAuthorization
Opposite
OwnerPriorAuthorization
Owning Association
Owning Template Parameter
Qualified NameFHIM::EnrollEligCOB::PriorAuthorization::nbrOfRefillsAuthorized
Stereotype
Template Parameter
Type«REAL» Decimal
Upper1
Upper Value(1)
VisibilityPublic


 orderablePharmacyItem
Public OrderablePharmacyItem orderablePharmacyItem

Pointer to the medicinal product that is the subject of the pre-authorization request. Note that this property may seem redundant as the Pharmacy Order contains an ordered item and points to the Prior Authorization class that owns this property. It is not redundant, however, as the pre-authorization may have occurred before the order occurs, and may be for a (slightly) different orderable medication, for example, the prior authorization may have been for a brand name drug, but a generic version is ordered.

Constraints:
Properties:

AggregationNone
Alias
AssociationpriorAuthorization_orderablePharmacyItem
Association End
ClassPriorAuthorization
Datatype
Default
Default Value
Is Compositefalse
Is Derivedfalse
Is Derived Unionfalse
Is Leaffalse
Is Orderedfalse
Is Read Onlyfalse
Is Staticfalse
Is Uniquetrue
Keywords
Lower0
Lower Value(0)
Multiplicity0..1
NameorderablePharmacyItem
Name Expression
NamespacePriorAuthorization
Opposite
OwnerPriorAuthorization
Owning Association
Owning Template Parameter
Qualified NameFHIM::EnrollEligCOB::PriorAuthorization::orderablePharmacyItem
Stereotype
Template Parameter
TypeOrderablePharmacyItem
Upper1
Upper Value(1)
VisibilityPublic


 quantityAccumulated
Public «PQ» Quantity quantityAccumulated

The amount of medication previously dispensed and paid for under this authorization. Used to determine the quantity remaining for billing under this authorization.
"Accumulated authorized amount expressed in metric decimal units." - NCPDP Telecommunication (Field 498-PX, Data Dictionary 201104).

Constraints:
Properties:

AggregationNone
Alias
Association
Association End
ClassPriorAuthorization
Datatype
Default
Default Value
Is Compositefalse
Is Derivedfalse
Is Derived Unionfalse
Is Leaffalse
Is Orderedfalse
Is Read Onlyfalse
Is Staticfalse
Is Uniquetrue
Keywords
Lower0
Lower Value(0)
Multiplicity0..1
NamequantityAccumulated
Name Expression
NamespacePriorAuthorization
Opposite
OwnerPriorAuthorization
Owning Association
Owning Template Parameter
Qualified NameFHIM::EnrollEligCOB::PriorAuthorization::quantityAccumulated
Stereotype
Template Parameter
Type«PQ» Quantity
Upper1
Upper Value(1)
VisibilityPublic


 status
Public «CS» Code status

"The status of the prescription’s prior authorization as known by the sender." - NCPDP Script (Field 7891, Data Dictionary 201104)

Constraints:
Properties:

AggregationNone
Alias
Association
Association End
ClassPriorAuthorization
Datatype
Default
Default Value
Is Compositefalse
Is Derivedfalse
Is Derived Unionfalse
Is Leaffalse
Is Orderedfalse
Is Read Onlyfalse
Is Staticfalse
Is Uniquetrue
Keywords
Lower0
Lower Value(0)
Multiplicity0..1
Namestatus
Name Expression
NamespacePriorAuthorization
Opposite
OwnerPriorAuthorization
Owning Association
Owning Template Parameter
Qualified NameFHIM::EnrollEligCOB::PriorAuthorization::status
Stereotype
Template Parameter
Type«CS» Code
Upper1
Upper Value(1)
VisibilityPublic