Procella HelpdeskProcella prior authorization load v2.1
- The file should be a pipe delimited text file
- Our batch load process expects the file name to contain the text “PRIORAUTH”. Example file names : PA_PRIORAUTH_sample.txt or PA_PRIORAUTH.txt
- The text file should contain the header row
| Field | Mandatory ? | Description | Comments |
| Filler | No | Can be left Blank | |
| groupId | Yes | External Group ID | |
| cardholderId | Yes | Cardholder ID | Will be used for Member Identification |
| personCode | Yes | Person Code | |
| firstName | Yes | First Name of the member | |
| lastName | Yes | Last Name of the Member | |
| dateOfBirth | Yes | DOB of the Member Expected Format | |
| authTypeCode | No | The type of Authorization being submitted. 1 - Prior Authorization | Default is 1 - Prior Authorization |
| drugLevel | Yes | The Drug Level for the Authorized Drug. NDC-9 | |
| drugLevelValue | Yes | The value representing the authorized drug level. | Alphanumeric. No dashes |
| ApplicableBrandClass | No | Values :
| If provided as Generic A criteria with be created with “drug level/value AND drug.PBMBrandClass bgwt Generic” Bgwt = Begins With Note : The letter case matters here. So it should be given exactly as its provided in the values |
| authLevelCode | No | 01 - Level 1 02 - Level 2 03 - Level 3 04 - Level 4 05 - Level 5 06 - Level 6 07 - Level 7 08 - Level 8 09 - Level 9 10 - Level 10 | Currently defaulting to 02 |
| outcomeCode | Yes | 1 - New 2 - Approved 3 - Denied 4 - In Process 5 - Withdrawn | |
| outcomeReasonCode | No | 1 - Special Request 2 - Medical Necessity 3 - Satisfies PA Criteria 4 - Client Request 5 - Does Not Meet Criteria 6 - Transitional 7 - Missing Documentation 8 - Denial Upheld 9 - Denial, Appealed 10 - Other | If not available, we can default to a value. Can be defaulted to 3 - Satisfies PA Criteria |
| authReasonCode | Yes | 1 - Allergy 2 - 2nd Appeal 3 - 3rd Appeal | If not available, we can default to 4 - Medical Exception |
| authPriorityCode | No | 1 - Standard Priority 2 - Urgent/Expedited | If not available, we can default to 1 |
| authByInfo | Yes, when outcomeCode = 2 or 3 or 5 | Name of person who approved/denied PA | |
| externalTrackingNumber |
Yes | External PA Tracking Number | This external tracking number is unique for the Prior Authorizations for a member. This id will be used to identify the PA when a update needs to be happen. |
| PA Tracking Number | No | User entered PA tracking number | If the PA tracking number is provided, we store the given value. If the PA tracking number is not provided, then we auto-assign a PA tracking number |
| Require PA Tracking # on claim | No | 0 - False 1 - True | If given as 1 , then PA tracking number in the above field should match with the PA tracking number in the claim. Default to 0 if not provided. |
| authComment | No | ||
| prescriberInfo | No | First and Last Name of Prescriber | |
| authNumberOfFills | No | The No of fills authorized for the member | We will default to a number, if this is not received UI defaults to 9999 |
| authStartDate | Yes | Authorization Start Date for the Member | Expected Format YYYY-MM-DD |
| authEndDate | Yes | Authorization End Date for the Member | Expected Format YYYY-MM-DD |
| authRequestStartDateTime | No | Date/Time when the request was received | We can take system date time. YYYY-MM-DD<space>HH:MM:SS |
| authRequestEndDateTime | No | Date/Time the authorization process was completed | We can take system date time. YYYY-MM-DD<space>HH:MM:SS |
| changeFormularyStatus | No | 0 - No OVERRIDE 1 - No Formulary 2 - Formulary, Open 3 - Formulary, Closed 4 - Non-Formulary | Default is 0 - NO OVERRIDE |
| changePreferredDrugStatus | No | 0 - NO OVERRIDE NP - Non-Preferred Drug XP - No Preferred Drug P1 - Preferred Drug Tier 1 P2 - Preferred Drug Tier 2 P3 - Preferred Drug Tier 3 P4 - Preferred Drug Tier 4 P5 - Preferred Drug Tier 5 P6 - Preferred Drug Tier 6 P7 - Preferred Drug Tier 7 P8 - Preferred Drug Tier 8 P9 - Preferred Drug Tier 9 P0 - Preferred Drug Tier 0 | Default is 0 - NO OVERRIDE |
| bypassAge | No | 0 - False 1 - True | |
| bypassClaimMinMax | No | 0 - False 1 - True | |
| bypassDaw | No | 0 - False 1 - True | |
| bypassDaysSupply | No | 0 - False 1 - True | |
| bypassQuantity | No | 0 - False 1 - True | |
| bypassQuantityPerDay | No | 0 - False 1 - True | |
| bypassSafetyEdits | No | 0 - False 1 - True | |
| bypassStepTherapy | No | 0 - False 1 - True | |
| Filler | No | should be left Blank | Placeholder to add for quantity allowed |
| Filler | No | should be left Blank | Placeholder to add for days for quantity allowed |