expresspa user guide - login user guide... · 2013. 8. 23. · and section 2 (registration and...

EXPRESSPATH PROVIDER PORTAL USER GUIDE

AUGUST 2013

© 2013-2020 Express Scripts, Inc. All rights reserved. No part of this publication may be reproduced or transmitted in any form or

by any means, electronic or mechanical, including photocopy, recording or any information storage and retrieval system, without the express written consent of Express Scripts, Inc.

All trademarks and service marks are the property of their respective owners.

This document is proprietary to Express Scripts, Inc. Unauthorized use and distribution are prohibited.

August 2013

Getting ExpressPAth Overview

09/26/2011 ExpressPAth User Guide

Sales & Marketing: Client Applications & Training

© Express Scripts, Inc.

1-1

Section 1: ExpressPAth Overview

ExpressPAth Overview ..................................................................................................1-3

Accessing ExpressPAth ..................................................................................................1-4

Creating a Desktop Shortcut for ExpressPAth ...........................................................1-5

Navigating .......................................................................................................................1-7

Printing ............................................................................................................................1-8

Accessing the User Guide ..............................................................................................1-9

Accessing Tutorials ........................................................................................................1-9

Using Support .................................................................................................................1-10

Logging In .......................................................................................................................1-12

Forgot Your User ID or Forgot Your Password .........................................................1-14

Forgot Your User ID? ..................................................................................................1-14

Forgot Your Password? ................................................................................................1-21

Logging Off .....................................................................................................................1-22

ExpressPAth Overview

1-2 ExpressPAth User Guide



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ExpressPAth Overview

The ExpressPAth Provider Portal - https://www.express-path.com - is a web-based

portal that can be used to request prior authorization for drugs and services for patients

who are covered under certain health plans’ pharmacy and/or medical benefits.

Prescribers and Providing Facility office managers can complete registration and

designate medical and non-medical staff to manage prior authorizations on their behalf.

ExpressPAth is available to registered users 24 hours a day, 365 days a year. The

convenience of an online tool allows the user to begin and complete an authorization

request on their schedule. Also, following up on a request is as simple as entering in

the patient information and viewing the results as time allows during a busy work day.

Using ExpressPAth has other advantages for providers and their office staff as well.

Here are just a few:

Increase efficiency by reducing paper forms, faxing time or time on the phone

Providers can manage their own information or designate others to request prior

authorizations on their behalf

Manage renewal requests electronically

Upload or fax additional documentation, such as lab results or other clinical

information, to support the prior authorization request

https://www.express-path.com/

Accessing ExpressPAth




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Accessing ExpressPAth

ExpressPAth Provider Portal is compatible with Microsoft Internet Explorer (versions

6, 7, and 8) and Firefox. It is also supported by both Apple and Windows Safari

Browser.

To access ExpressPAth:

1. Double-click or the icon for your web browser.

2. In the Address field, type the ExpressPAth URL.

This URL is https://www.express-path.com

Notes: Do NOT add the ExpressPAth URL to your Favorites, or you may

have problems accessing the most current version of the Provider

Portal if we release a new version. You may add a shortcut (see

instructions on page 5 of this section).

Pop-up Ad Blocker must be turned OFF.

3. Press Enter





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Creating a Desktop Shortcut for ExpressPAth

To create a Desktop shortcut for ExpressPAth:

1. Go to your Desktop.

2. Right click your mouse in any blank area on your Desktop.

A menu appears when you right-click.

3. Move your mouse to the “New” menu option.

A secondary menu appears.

Creating a Desktop Shortcut for ExpressPAth




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4. On the secondary menu, select

The following box appears.

5. Place your mouse inside the text box. Type the URL below.

is https://www.express-path.com

6. Click The following box appears.

7. Type a name for the shortcut in the field provided. For this example, we will

use “ExpressPAth”.

8. Click The box closes.

The Desktop shortcut is now ready.





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Navigating

You can navigate through ExpressPAth using several methods.

To access different sections of ExpressPAth, use the tabs that are located at the

top of each page.

Hyperlinks are embedded into forms in the work area

And on the left side of pages

or

Buttons are embedded into left menus and into work area forms

The Stage Progress indicator at the top of the ExpressPAth work area checks

off steps as they are completed.

Printing




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Printing

Any user in ExpressPAth Provider Portal has the ability to print the screen using the

icon anywhere within the application. This print icon is located on every page

towards the top right corner of the screen.

Note: Only the information that appears on your screen display is printed.

If the record is longer than your screen display, you must scroll up

or down in the record and repeat the process above if you want to

print information further up or down in the record.





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Accessing the User Guide

You can access a PDF of the User Guide from a link within ExpressPAth.

To access the User Guide:

From any page, click Help in the top right corner of the screen.

A PDF of the ExpressPAth User Guide appears. You are automatically taken to a

specific point within the user guide based on the tab and/or link that you are working in

within ExpressPAth.

If you are not yet logged in to ExpressPAth, you will only see Section 1 (Overview)

and Section 2 (Registration and Settings). Once you login, you will also see all of the

remaining sections in the user guide.

Accessing Tutorials

You can access ExpressPAth video training modules from a link within ExpressPAth.

To access the tutorials:

1. From any page, click Tutorial in the top right corner of the screen.

A menu of tutorials displays. Based on the tab and/or link that you are

working in within ExpressPAth, you may see different tutorials that are

relevant to that section (e.g., not all tutorials that are available in ExpressPAth

will display in every tab).

2. Click on the desired tutorial to select it.

Navigational arrows, play & pause buttons display on the tutorial.

Note: There is no sound on any of the tutorial videos.

3. When the tutorial ends, you may replay it or click the red X to close it.

Using Support




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Using Support

You are able to request technical assistance by using the Support link.

To request technical assistance,

1. Click the Support link.

An email form opens.

2. Click the Priority dropdown arrow and select the priority of the issue. Press

Tab.

3. In the User ID field, type your User ID. Press Tab.

4. In the Enter your Email ID field, type your email address. Press Tab.

5. In the Subject field, briefly explain the issue that you are having with

ExpressPAth.





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6. In the Description field, type a detailed description of your ExpressPAth

technical issue.

Note: If your question is clinical, not technical, please contact the health

plan.

7. If needed, in the Attachment file field, click the Browse button and add an

attachment to the support request.

8. In the Enter the code as shown in Image field, type the code as seen in the

spatter box.

9. To submit your request for support, click

10. Someone on the ExpressPAth Support team will reach out to you as they work

to resolve your issue (typically within one to two business days).

Logging In




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Logging In

Login area displays before a user logs into ExpressPAth and is also

used for registration.

Work area contains active information and forms while working in

ExpressPAth.

NIH News contains links to National Institute of Health news.

To log in to ExpressPAth:

1. In the Enter your User ID field, type your previously selected User ID.

2. In the Enter your password field, type your previously selected case-

sensitive password.

Note: Your password for ExpressPAth expires every six months.

3. In the Enter the below text field, type the code number displayed in the

shaded security code area.

4. Click the Sign In button or press Enter on your keyboard.





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After you have registered or logged into ExpressPAth, the Prior Authorization Portal

for Providers page displays.

Prior Authorization, Settings, and Logout tabs display after a registered

user logs into ExpressPAth. The active tab is yellow.

Prior Authorization Portal for Providers contains hyperlinks and buttons

to initiate, complete, search for a previously submitted PA request, or search

for prior authorizations about to expire.

Note: If ExpressPAth is inactive for 20 minutes, you will automatically be

logged out of the tool. ExpressPAth will show you as logged out, but

a Login link on the page allows you to immediately log back in.

Forgot Your User ID or Forgot Your Password




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Forgot Your User ID?

To recover your ExpressPAth User ID:

1. On the ExpressPAth Login tab page left column, click on the Forgot your

User ID link.

The I am a field dropdown displays.

2. To identify your role in ExpressPAth, click the dropdown arrow.





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Your choices are Prescriber, Agent, or Providing Facility.

3. Select the role (which you chose during registration) that best describes you.

You are moved to the next step.

For Prescribers:

If you are a Prescriber, the form below displays.

1. In the Who is a field, click the dropdown and select the correct descriptor

(which you chose during registration) that best describes you.

2. You have a choice of which prescriber ID you enter. Select either the DEA,

NPI or SLID (State License ID) field and type the appropriate ID.

Note: Only your NPI is required during registration. DEA and State License

ID (SLID) are not required during registration. If DEA and State

License ID were not entered during registration, a search by DEA or

SLID will be unsuccessful.





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3. In the Email ID field, type your email address.

4. Click

If your information does match the information in the system, Secret

Question and Answer fields display as part of the Forgot your User ID?

login.

5. In the Answer field, type the correct answer to the Secret question that you

selected during registration.

6. Click

A message displays indicating that your user ID has been sent to your email

address.

When you open your email, you will see an email message from ExpressPAth

stating, “The following User ID has been requested for (Requestor Name) :

abc123

The email contains a link to use “to continue, creating, modifying and

checking the status of prior authorizations with the User Id provided above.”





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For Agents:

If you are an Agent, the form below displays.

1. In the I work at a field, click the dropdown arrow and select the correct

descriptor (which you chose during registration) that best describes your

office location.

2. In the NPI field, type the NPI of a prescriber or provider to whom you are

associated. This is a required field.

1. First Name and Last Name fields are optional.

4. Optional: In the PPI field, type the unique ExpressPAth Prescriber ID that

was sent to the Physician for whom you are an agent. This number is

available in the physician’s activation email.

5. In the Email ID field, type your email address. This is a required field.

6. Click





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login.



8. Click


address.

When you open your email, you will see an email message from ExpressPAth

stating, “The following User ID has been requested for (Requestor Name) :

abc123





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For Providing Facilities:

If you are a Providing Facility, the form below displays.

1. In the I work at a field, click the dropdown and select the correct descriptor

(which you chose during registration) that best describes your office location.

2. You have a choice of which providing facility ID you enter. Select either the

DEA, NPI or SLID (State License ID) field and type the appropriate ID.

Note: Only your NPI is required during registration. DEA and State License

ID (SLID) are not required during registration. If DEA and State

License ID were not entered during registration, a search by DEA or

SLID will be unsuccessful.

3. In the Email ID field, type your email address.

4. Click





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If your information does not match the information in the system, the

following message displays.



login.

Note: The example shown is for an agent, but is similar for all users.



7. Click


address.

When you open your email, you will see an email from ExpressPAth stating,

“The following User ID has been requested for (Requestor Name) : abc123.

The email contains a link to use “to continue, creating, modifying and

checking the status of prior authorizations with the User Id provided above.”





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Forgot Your Password?

After you have entered your user ID, if you are unable to recall your password:

1. Click the Forgot your password? link.

2. For your assigned role, follow the same instructions given for Forgot your

user ID?





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Logging Off

You can log off at any time.

To log off, click the Logout tab.

A message displays that you have successfully logged out.

Note: You will automatically be logged out of ExpressPAth after 20 minutes

of inactivity.

A link displays to log back in.

Section 2―ExpressPAth Registration and Settings


Client Application Training Department


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Navigating the ExpressPAth Login ...............................................................2-3

Registering Prescribers and Providers ..........................................................2-4

Registering as a Prescriber/Provider .................................................................2-6

Setting Your User ID and Password .................................................................2-10

Registering Agents ...........................................................................................2-12

Registering as an Agent ....................................................................................2-12

Settings - Managing Your Profile Information - Providers ........................2-22

My Information (Providers) ..............................................................................2-22

My Practice Locations (Providers) ....................................................................2-26

My Agents (Providers) ......................................................................................2-30

Adding an Agent ...............................................................................................2-31

Searching for an Agent ......................................................................................2-32

Settings - Managing Your Profile Information - Agents .............................2-40

My Information (Agents) ..................................................................................2-40

My Physicians (for Agents) ..............................................................................2-42

My Physician Agents (for Agents) ....................................................................2-51

Creating a List of Favorite Rendering Providers (Providers and Agents) 2-53

Viewing Your Favorites ....................................................................................2-53

My Favorite Rendering Providers .....................................................................2-54

Changing Your Password (Providers and Agents) ......................................2-63

Navigating the ExpressPAth Login


© Express Scripts, Inc. 06/01/2011

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Section 2―Provider Portal Registration




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Navigating the ExpressPAth Login

The Login Page is where registered users will login or new users will register to use

ExpressPAth. On the right side, NIH (National Institutes of Health) news is displayed.

When you launch ExpressPAth, the first page you will see is the Login Page.

Some of the elements you will encounter on this page include:

Login tab

Login area is where registered users log in to ExpressPAth and new users

register to use the tool. A security code displays and must be entered during

every login. When login is complete, users click the Sign in button to

proceed.

ExpressPAth work area: Displays a brief description of prior authorization

tasks that may be performed in ExpressPAth.

Help area: Help, Tutorial, and Support links are located here.

NIH News Column contains National Institutes of Health article links

Registering Prescribers and Providing Facilities


© Express Scripts, Inc. 06/01/2011


These instructions are for registering the following ExpressPAth users:

Physicians Home Infusion Therapy Providers

Pharmacists Specialty Pharmacies

Nurse Practitioners Outpatient Facilities

Physician Assistants Dialysis Centers

To register as an ExpressPAth user:

1. Go to the ExpressPAth website at https://www.express-path.com.

2. On the ExpressPAth Login tab page left column, click on the Click Here to

Register link.





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During the registration process, the page display changes.

Stage Progress indicator at the top of the ExpressPAth work area checks off

steps in the registration process as they are completed.

Progress Bar displays on the left side of the page to visually indicate the

registration stage and the remaining steps.


2-6 Provider Portal User Guide



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Registering as a Prescriber/Providing Facility

Step 1: Terms and Conditions:

1. In the Image Verification Code field, type the code that you see in the picture.

2.. Read the Service Agreement. You will need to scroll down to review the complete

agreement.

3. To agree to the terms of the Service Agreement, click the Accept radio button.

4. Click

Clicking the Decline radio button terminates the registration process.





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Step 2: Define Your Role:

1. To the right of “I am a”, click the dropdown arrow

Note: Fields followed by a red asterisk (*) are required.

. Refer to the table below for assistance in populating these fields:

If you are registering as a:

In the following field:

Select from the following:

Prescriber

Who is a Physician

Physician Assistant

Pharmacist

Nurse Practitioner

Providing Facility

I work at a Physician Office

Home Infusion Therapy

Agency

Specialty Pharmacy

Outpatient Facility

Dialysis Center

Step 3: License Information and Upload License:

1. In the NPI field, type your NPI number. This is a required field.

NPI: The National Provider Identifier (NPI) is a unique identification number for health

care providers issued by the National Plan & Provider Enumeration System (NPPES) that

will be used by all health plans. NPIs are issued to health care providers in order to

submit claims or conduct other transactions specified by HIPAA.

Note: If you are registering as an individual prescriber or provider, use your individual

NPI. If you are registering as a providing facility, use your organizational NPI.

State License (optional): Number issued on a State Medical License by the state where

the physician practices medicine.





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To upload your license from an electronic file, click the Upload checkbox and then click the

button.

A copy of your license is required to validate your credentials.

2. Locate the license file saved on your computer and select it.

The file address will display in the field.

Note: The file must be 4MB or less and must be in JPG, TIFF, GIF, PDF, BMP, DOC

or DOCX format. The ExpressPAth Registration Validation team will validate

your credentials prior to sending your registration activation confirmation email

(within two business days of receiving a legible copy of your credentials).

3. To upload the file, click the button.

Note: If you do not have an electronic copy of your license, you can fax your license

by clicking the Fax checkbox. Then, download a copy of the fax cover sheet by

clicking on the hyperlink. Fill out the information requested on the cover sheet

and fax it along with a copy of your license to the fax number on the screen.

4. Click

If your NPI is located in the CMS (Centers for Medicare and Medicaid Services)

database, your demographic information will be pre-populated on the form.

If your demographic information is not found in the CMS database, you can enter it

manually.

Note: If you manually update your demographic information in ExpressPAth, you will

need to contact CMS in order for your updates to be reflected in that database.





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Step 4: About You:

1. Verify that this information is correct (all fields are editable, if necessary).

or

Manually enter the data.

2. In the Enter your Email ID field, type your email address.

You will be asked to enter your email address twice to validate this field. Both emails

must match.

To disable email notifications, place a check in the box next to the

box

Or

If you do not opt out, you will receive an email every day that there is activity in any of

the listed categories for PA’s that you are associated with:

LOW: You will receive a daily summary showing a total of all approvals, denials,

withdrawals, or PA’s requiring further information for that day.

MEDIUM (default): In addition to receiving low notification emails, you will get an

email each time a PA that you intiated (or a PA that you are associated with) requires

further information for you to enter/submit.

HIGH: In addition to receiving low and medium notifications, you will get an email

notification each time a PA you intiate or are associated with is approved, denied, or

withdrawn.





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3. In the Specialty field, click the Specialty dropdown and select your specialty

or

In the Taxonomy Code field, enter your taxonomy code number. The Health Care Provider

Taxonomy codes are national specialty codes used by providers to identify their specialty

category. The codes are created by the National Uniform Claim Committee (NUCC), which

is chaired by the American Medical Association. Paste the link below into your web browser

in order to obtain the list of taxonomy codes and to identify the correct code to use for your

specialty.

http://www.nucc.org/index.php?option=com_wrapper&Itemid=50

When one of these fields has been populated, the other field auto-populates.

4. Click

Setting Your User ID and Password

Step 5: Login Information:

1. To enter your User ID, in the User ID field, enter your own unique user ID, then click

the button to confirm that ID is available

or

To have ExpressPAth suggest a unique User ID for you, click the button.

2. In the Password field, type your password.

Note: Passwords must be at least six characters long and must contain at least one

upper case character, one lower case character, one digit and one special

character.






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3. In the Re-enter Password field, retype your password.

4. In the Secret Question field, click the dropdown arrow and select a secret question.

5. In the Answer field, type the answer to your secret question. If you forget your

password, this will be used to verify your identity.

To complete the registration process, click the button.

Step 6: Registration Complete:

A message displays that indicates that you will receive a confirmation/activation email

within two business days after the ExpressPAth Registration/Validation team has

received a legible copy of your state license/credential information.

IMPORTANT: Please add [email protected] to your list of email contacts so that

the activation confirmation email does not go to your Spam/Junk email folder.

6. Click the Close button to complete your registration.

7. Once the confirmation/activation email is received from the ExpressPAth team (usually

within two business days), you can begin using ExpressPAth for prior authorization

requests for patients with participating health plans.

mailto:[email protected]





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Registering Agents

These instructions are for registering ExpressPAth users who are Agents. An Agent is anyone

who can perform Prior Authorization functions on behalf of a Prescriber or Providing Facility.

Examples of Agents include medical or non-medical office staff such as:

Office Managers

Administrative Assistants

Secretaries

Nurses

Important: An Agent cannot register until their associated Prescriber or Providing

Facility has completed the registration process in ExpressPAth. The

Prescriber/Providing Facility does not have to be activated for the agent to

register.

To register as an ExpressPAth Agent:

1. Go to the ExpressPAth website at https://www.express-path.com.

2. On the ExpressPAth Login tab, click on the Click Here to Register link on the left-

hand side.

The ExpressPAth Home Tab displays.

Registering as an Agent

Step 1: Terms and Conditions, as follows:





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2. In the Image Verification Code field, type the code that you see in the picture.

3. Read the Service Agreement. You will need to scroll down to review the complete

agreement.

4. To agree to the terms of the Service Agreement, click the Accept radio button.

5. Click

Clicking the Decline radio button terminates the registration process.

Step 2: Define Your Role form: On the I am a dropdown list, select Agent.





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7. Step 3: License Information:

8. In the I work at a field, click the dropdown arrow.

9. Select the appropriate agent work location description.





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You must associate yourself to a physician or providing facility by one of the

following:

by NPI

by Facility Name

by First and Last Name

PPI

Note: PPI is a unique ExpressPAth ID that is sent to the Physician when they register.

This number is available in the physician’s activation email and is not a required

field.

Search for an existing physician: enter required information to locate a prescriber or provider:

1. In the NPI field, type the prescriber or providing facility’s NPI number

or

In the Facility Name field, type the name of the providing facility

or

In the First Name field and the Last Name field, type the prescriber or provider’s

name.

2. Click

If the physician is located, the Prescriber Search box displays.





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3. If the correct physician is displayed, in the Prescriber Name field, click the

prescriber’s name hyperlink.

Note: If more than one page of records is returned, use the left and right arrows on the

bottom right to navigate back and forth within the records.

Step 3: License Information: redisplays in the work area, with the NPI and Name fields

populated with the prescriber information.

4. If you support more than one physician, you will repeat the search information for

additional physicians by clicking

You may add up to 10 prescribers/providers during registration.

Note: Additional prescribers/providers can be added by accessing the Settings tab and

adding them through the My Physicians link once you have completed your

registration. See the Settings - Managing Your Profile Information – Agents

section for instructions on how to add prescribers/providers through your

Settings tab.

5. When all physicians (up to ten) have been added to your profile, click





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Step 4: About You:

1. In the First Name field, type your first name (required field).

2. In the Last Name field, type your last name (required field).

3. In the Enter your email address field, type your email address (required field).

4. In the Retype Email ID field, type your email address again (required field).


box

or










withdrawn.

5. Click





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Step 5: Login Information:

1. In the User ID field you may enter your own unique user ID, then click the

button to confirm that ID is available.

or

To have ExpressPAth suggest a unique User ID for you, click the button.

2. In the Password field, type your password.

Note: Passwords must be at least six characters long, and must contain at least one

upper case character, one lower case character, one number and one special

character.

3. In the Re-enter Password field, retype your password.

4. In the Secret Question field, click the dropdown arrow and select a secret question.

5. In the Answer field, type the answer to your secret question. If you forget your

password, this will be used to validate you.

6. To complete the registration process, click the button.

The Registration Complete page displays in the work area, shaded, with a Thank You

popup message in front. It describes how an email has been sent to each of the

designated providers with instructions for them on how to activate the Agent’s account.





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7. To exit, click

Prescriber/Provider Confirms Association to Agents

The last step to allow agents to perform Prior Authorization tasks on their behalf is for the

prescriber/provider to finalize the agent’s association request.

The prescriber/provider receives an Agent Authentication email that an agent has requested

association to them. Within the email there is a link to the Agent Authentication form.

To confirm an agent association to a prescriber/provider:

1. Click the link provided in the email from ExpressPAth (([email protected]) or

paste the URL in the email into your internet browser address bar.

Note: You will need to login before you are taken to the agent authentication form.






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The My Agent page displays.

2. Set the Agent Status field to Active.

Other Agent information fields become available.

The Start Date default is today’s date.

3. To change the start date, in the Start Date field type the start date in the following

format: MM/DD/YYYY

4. In the Deactivate Agent on field, change the date from today’s date to any date in the

future. If you wish to make this agent active until you manually deactivate them, type

in 12/31/2099 in this field.

5. In the Assign Privileges area, select all of the privileges you want to apply to this

agent.

6. When all of the desired check boxes are populated, click the button

A pop-up confirmation message displays and an email is sent to the Agent to notify

them that they are now able to perform Prior Authorization tasks on behalf of the

prescriber/provider.

Note: The prescriber/provider’s account must have been validated and activated in

order for the agent to perform PA tasks for that prescriber/provider.





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7. Click

The Settings tab opens on the My Agents page. Click the Home link near the top left

corner of the screen to return to the ExpressPAth landing page.

Settings - Managing Your Profile Information - Providers




09/13/2011


By accessing the Settings tab in ExpressPAth, you are able to manage your profile information,

including editing your information and changing your password. Providers and providing

facilities are also able to view, edit, or add practice locations and add agents, deactivate agents

and manage associated agents’ privileges.

My Information (Providers)

Viewing Your Credential Information

1. Click on the Settings tab.





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The Settings page displays in the work area with the Account Home menu open.

2. Click the My Information link.

or

Click My Information

The My Credential Information page displays.

Locked fields display with gray text. These cannot be edited.

Editable fields display with black text.





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Editing Your Credential Information



The My Credential Information page displays.

3. You may edit any editable field (those without greyed out text).

Note: The Address fields, Work Phone, Email, Specialty, Taxonomy Code and

Secret Question and Answer fields are editable and required, as indicated by a

red asterisk (*).

4. To save your edits, click

Note: If the email associated to you is shared by another user ID, a popup message

will display, asking “Are you sure you would like to continue to update the

system with this email address?”

Click to continue.

or

Click to end the action.

Note: Any Agent with Office Manager privileges is able to edit a provider’s My

Information page. They are not able to change the provider’s password or

secret question/answer.

Note: Any updates made to your profile in ExpressPAth will not be reflected in the

Centers for Medicare and Medicaid Services (CMS) database. Please contact

CMS to ensure your records on file are current.

E-mail Summary


box

or









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withdrawn.





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My Practice Locations (Providers)

Viewing Practice Locations


2. Click the My Practice Locations link.

or

Click My Practice Locations

A list of Practice Locations associated to you displays.





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Editing a Practice Location



or

Click the My Practice Locations

A list of My Practice Locations associated to you displays.

3. Click the Edit link associated to the desired location.

The existing location information displays as a form.

4. Make edits to the location.

Note: Fields marked by a red asterisk (*) are required fields and must be

populated.

5. To save your changes, click

or

To cancel without saving your changes, click





09/13/2011

ExpressPAth saves the changes to the selected practice location and returns

you to My Practice Locations.

Adding a Practice Location



or


A list of Practice Locations associated to you displays.

3. Click the Add link.

A blank location form displays.

4. Enter information for the added practice location to the form.

Note: The Address Line1, City, State, Zip, and Type (only one primary

location type is allowed – all others must be secondary) fields are

required.





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5. Click

ExpressPAth saves the new practice location and returns you to My Practice

Locations.

Deleting a Practice Location



or


A list of My Practice Locations associated to you displays.

3. Click the Edit link associated to the desired location.

The existing location information displays as a form.

4. Click .

ExpressPAth returns you to My Practice Locations. The deleted practice

location is no longer listed.





09/13/2011

Note: Any Agent with Office Manager privileges is able to manage their

associated provider’s My Practice Locations profile. They are able to

add, edit or delete practice locations on behalf of the provider.

My Agents (Providers)

Registered Providers and their Agents designated as Office Managers are able to

initiate, confirm and manage agent associations in ExpressPAth. The My Agents page

is used to assign, edit, or remove agent privileges, and to add additional agents.

To view My Agents:


The Settings page displays with the Your Options menu open.

2. To view your associated agents, click the My Agents link.

or

Next to My Agents click

The My Agents page displays in the work area.





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In the My Agents area, a list of agents to whom you are associated displays.

Note: The current privileges assigned to an agent are listed in the Privileges

field.

Adding an Agent

You are able to initiate an association to an agent by locating the agent and adding the

agent to your agent list. The agent must be registered and associated to at least one

other provider in the ExpressPAth Provider Portal in order for the agent to return in the

search results.

To add an agent:

In the upper right corner of the My Agents page, click the My Agents Add

link.





09/13/2011

The Search for an Agent popup box displays. You will search in the system for the

agent. You may search for an agent by first and last name or by email.

Searching for an Agent

1. Populate the First Name and Last Name fields

or

Populate the Email field with the desired agent’s information.

2. Click





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If there are matches to the search, ExpressPAth displays the search results

beneath the search criteria.

3. Click on the hyperlink of the agent’s name.

If the agent is already associated to you, the message “Agent Already

associated with Physician” displays.

The agent must be registered and associated to at least one other provider in

ExpressPAth in order for the agent to return in the search results. Otherwise,

the following message displays.





09/13/2011

If the searched-for agent is not associated to the provider and has registered as

an agent for any other provider in ExpressPAth Provider Portal, the agent will

be included in the search results.

When the agent has been selected by clicking on the hyperlink with their

name in the search results, the Assign Privileges to Agent pop-up box

displays.

4. To assign privileges to the agent, click the checkboxes to select the desired

privileges.

5. To confirm the assignment of privileges, click

or

To cancel the assignment, click

A message displays, indicating the Agent’s record has been updated.

ExpressPAth adds the selected agent to your My Agents list.

A confirmation email is sent to the agent’s registered email, containing login

instructions.

Note: Agents receive emails to inform them that they have been activated by

their providers and that they are now able to perform assigned prior

authorization privileges on their behalf.

Note: Agents with Office Manager privileges are able to manage their

providers’ My Agents settings. Office Managers have the ability to

add agents, as well as edit their privileges, or deactivate agents on

behalf of their associated providers.





2-35

Editing My Agents

You are able to edit privileges assigned to agents, to change the agent’s status, and to

amend the period of privileges.


The Settings page displays with the Your Options menu open.

2. Click the My Agents link.

or

Next to My Agents click

The My Agents page displays in the work area.





09/13/2011

4. Locate the agent for whom edits are required.

5. Click the associated Edit link.

The My Agent (Edit Agent Information) page displays in the work area.

6. To edit the agent’s privileges, click the Assign Privileges checkboxes to

select or deselect privileges.

7. To edit the agent’s status, click the Agent status dropdown arrow.

If you are changing agent status from “Inactive” to “Active,” you must also

assign at least one privilege to the agent before you are able to save the edits.

8. To edit the dates in the Deactivate Agent on field, click the calendar

or

Type the amended date in the Deactivate Agent on field (MM/DD/CCYY).

Note: In order to deactivate an agent immediately, the Provider must choose

a date prior to the current date in the Deactivate Agent On date field.

An agent can also be deactivated on any date in the future by selecting

that date. When that date arrives, the agent’s status will automatically

be changed to “Inactive” in ExpressPAth.





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9. To save your edits, click

Note: If you assign the Office Manager privilege to more than three users,

subsequent office manager assignments will prompt a popup to

display. The popup indicates that at least three office managers have

been assigned and asks if you are sure you want to assign another.

10. To proceed, click

ExpressPAth saves the privileges. .

Authorizing an Agent Request

When an agent has registered and associated themselves to the prescriber, the

prescriber receives email notification.

To authorize the agent:

1. Open the Agent Activation email.

2. Click the link embedded in the email

or

Copy and paste the URL address string into your internet browser address

bar, and then click the Search icon.





09/13/2011

ExpressPAth displays the login screen.

3. Log into ExpressPAth.

The My Agent (Edit Agent Information) page displays.

3. Set the Agent Status field to Active.

Other Agent information fields become available.

The Start Date default is today’s date.

4. To change the start date, in the Start Date field type the start date in the

following format: MM/DD/YYYY





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5. In the Deactivate Agent on field, change the date from today’s date to any

date in the future. If you wish to make this agent active until you manually

deactivate them, type in 12/31/2099 in this field.

7. In the Assign Privileges area, select all of the privileges you want to apply to

this agent.

8. When all of the desired check boxes are populated, click the button

A pop-up confirmation message displays and an email is sent to the Agent to

notify them that they are now able to perform Prior Authorization tasks on

behalf of the prescriber/provider.

Note: The prescriber/provider’s account must have been validated and

activated in order for the agent to perform PA tasks for that

prescriber/provider.

The My Agent page redisplays with the changes displayed.

Settings - Managing Your Profile Information - Agents




09/13/2011


By accessing the Settings Tab in ExpressPAth, you are able to manage your profile

information, including editing your information and changing your password. Agents

are able to request association to additional providers/providing facilities, remove

association to providers/providing facilities and view other agents associated to their

providers/providing facilities.

My Information (Agents)

Agents are able to edit and update their settings in the ExpressPAth Provider

Portal.

To edit or update My Information:

1. When you have logged into ExpressPAth, click on the Settings tab.

On the left side of the page, a list of Your Options displays.

2. To edit your information, click the My Information hyperlink

or

Next to My Information, click





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You are able to edit the following fields: all Name fields, Email, Secret

Question, or Answer. You can also change your password here.

3. Click the desired field and type the updated information in the desired field.

5. When you are finished, click

E-mail Summary


box

or

If you do not opt out, you will receive an email every day that there is activity

in any of the listed categories for PA’s that you are associated with:

LOW: You will receive a daily summary showing a total of all approvals,

denials, withdrawals, or PA’s requiring further information for that day.

MEDIUM (default): In addition to receiving low notification emails, you

will get an email each time a PA that you intiated (or a PA that you are

associated with) requires further information for you to enter/submit.

HIGH: In addition to receiving low and medium notifications, you will get

an email notification each time a PA you intiate or are associated with is

approved, denied, or withdrawn.





09/13/2011

My Physicians (for Agents)

My Physicians is a repository for providers to whom you are associated.

To view My Physicians information:


The Settings Home page opens, with the Settings menu displayed.

2. Click on the My Physicians link.





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A list of physicians associated to the agent displays.

Adding My Physicians

To add physicians to your My Physicians list:







09/13/2011

2. Click on the My Physicians link.

A list of physicians or providing facilities to whom you are associated

displays.

3. Click the Add link.





2-45

The “Search for an existing Physician” pop up box displays.

There are four ways to search for a physician or providing facility.

Note: The physician or providing facility must have already registered for

ExpressPAth Provider Portal in order to display in the search results. They do

not have to be activated yet.

To search for a physician or providing facility by NPI number:

1. In the Physician NPI field, type the physician’s or providing facility’s NPI

number.

2. Click

To search for a physician by name:

1. In the First Name field, type the first name of the physician.

2. In the Last Name field, type the last name of the physician.

3. Click

To search for a providing facility by name:

1. In the Facility Name field, type the providing facility’s name.

2. Click

To search for a physician by PPI number:





09/13/2011

1. In the PPI field, type the ExpressPAth ID number that was assigned to the

provider during their registration.

2. Click Search results, if any, display beneath the search area.

If the desired physician or providing facility displays in the search results

area, to select the physician or providing facility:

1. Click on the Prescriber Name, which is a link.

You will use the Prescriber Name link even if you are selecting a Facility. If

no name is associated to the Facility, it will say “Unknown, Unknown” in the

Prescriber Name field.

2. The system adds the physician or providing facility to your My Physicians

list.

Note: An email is sent to the Physician or Providing Facility to inform them

that an Agent has requested association to them. The provider must

assign privileges and activate the agent through a link included in the

email before the Agent is able to perform prior authorization tasks on

their behalf.





2-47

Reminder to Activate

If a provider does not activate the agent in a timely manner, the agent is able to send an

email reminder requesting that the provider complete the activation.

To send a reminder to the physician to activate the agent:

1. In ExpressPAth, click on the Settings tab.

The Settings tab menu displays.

2. On the Settings tab menu, click the My Physicians link.

The physician or physicians to whom you have requested association display.

3. Locate the physician who has not activated.

Note: Agent Status will be “InActive.”

4. Click the Send Reminder to Activate link.





09/13/2011

A message displays, indicating that a reminder has been sent.

5. If the physician does not activate the agent in a few days, the agent can click

the “Send Reminder to Activate” link again and another email will be sent.

Disassociating from a Provider on your My Physicians List (Agent)

An agent who is associated to a provider is able to disassociate him/herself from the

provider by removing the physician from their My Physicians List.

As an Agent, to remove association from a provider:

1. On the ExpressPAth Provider Portal Home page, click the Settings tab.





2-49

2. The Settings page displays in the work area with the Account Home menu

open.

3. Click the My Physicians link.

The My Physician page displays.

Note: The system will display all Providers to which the Agent has

requested an association, even if they have not been activated yet.

The Agent has the ability to remove association for any provider listed

here.

4. For the desired physician, click the Remove link.





09/13/2011

A pop-up message displays, asking, “Do you want to remove this Physician?”

5. To continue removing the physician, click Yes.

A second pop-up message displays, stating, “Physician disassociated

successfully.”

6. Click OK.

Your My Physicians list redisplays. The disassociated physician is no longer

listed.

Note: When an Agent removes a Provider from their My Physicians list, an

e-mail is sent to the Provider.

Note: Once an Agent has disassociated from a provider, that Agent is no

longer able to perform prior authorization tasks on the provider’s

behalf.

An Agent may remove association to all providers, but they will not

be able to perform any prior authorization tasks in the ExpressPAth

Provider Portal once all associations are removed.





2-51

My Physician Agents (for Agents)

Viewing My Physician Agents

Physician Agents are other agents that an Agent’s physicians or providing facilities are

associated with in ExpressPAth. These other agents are also authorized to perform

specific prior authorization tasks on behalf of that physician or providing facility.







09/13/2011

2. Click on the My Physician Agents link.

A list of Physician Agents to whom your physicians or providing facilities are

associated displays.

If your physician or providing facility is not associated to any other agents,

the message “No Registered Agents available” displays.

No action may be taken on this page.

Note: Agents with Office Manager privileges will see both a My Physicians

link for all of their associated providers and/or providing facilities, as

well as a My Agents link for all other agents that are also associated

to their providers/providing facilities.

3. To return to the Settings menu, click the Settings tab.

or

To exit ExpressPAth, click the Logout tab.

or

To manage your prior authorizations, click the Prior Authorizations tab.





2-53

Creating a List of Favorite Rendering Providers (Providers and Agents)

In the ExpressPAth Provider Portal, you are able to create a list of up to twenty favorite

rendering providers, making it easier to select frequently used providers. Favorite

Rendering Providers may be added manually or by searching. They may also be edited

or removed.

Viewing Your Favorites







09/13/2011

The Settings page opens in the work area.

3. Click the My Favorite Rendering Providers link.

The My Favorite Rendering Providers summary page displays with your

current favorite providers, if any.

My Favorite Rendering Providers

To create your own list of favorite rendering providers, you will first need to search for

existing providers. If you are unable to locate the provider after searching, you will

need to add the provider. You are also able to edit rendering provider information.

Because there is a limit of twenty favorite providers, if you exceed your limit and want

to add a new rendering provider to your favorites, you will need to remove a provider

first and then add the new provider.





2-55

Searching for Favorite Rendering Providers


The Settings page opens in the work area, with the Settings menu open.

2. Click the My Favorite Rendering Providers link.





09/13/2011

The Search Rendering Provider page displays.

If you have no favorite rendering providers listed or if you want to add

another favorite provider to your list, start your search by locating providers

already in the system.

3. Click Search.

The Search Rendering Provider form pops up.

There are three ways to search for a rendering provider.

To search for a rendering provider by NPI number:

1. In the NPI field, type the rendering provider’s NPI number.

2. Click





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To search for a rendering provider by Facility Name:

1. In the Facility Name field, type the name of the facility.

2. Click

To search for a rendering provider by name:

1. In the First Name field, type the first name of the provider.

2. In the Last Name field, type the last name of the provider.

3. Click

The Search results display beneath the search criteria area.

4. If the desired prescriber/provider displays, in the Provider Name field, click

the provider’s name. This is a hyperlink.





09/13/2011

The selected provider displays as one of your favorite rendering providers.

5. If the desired provider does not display, click

You will need to manually add the provider.

Note: Favorite Providers do NOT have to be registered in ExpressPAth.

Adding a Favorite Rendering Provider

If a favorite rendering provider is not located by searching, you are able to manually

add the rendering provider.

To add a Favorite Rendering Provider:

1. On the My Favorite Rendering Providers home page, click Add.





2-59

The Add new Rendering Provider pop-up displays.

2. You must populate the mandatory fields indicated by a red asterisk (*) to

manually add a rendering provider.

Mandatory fields include:

NPI

First Name

Last Name

Address Line 1

City

State

Zip

Work Phone

Email Address

Specialty (Note: Selecting the Specialty automatically populates the

Taxonomy Code field)

Taxonomy Code (Note: Entering the Taxonomy Code automatically

populates the Specialty field)

3. You may also populate the Facility Name, Address Line 2 and Fax Number

fields (optional).

4. Click

The provider is added to your favorites.





09/13/2011

Editing a Favorite Rendering Provider

If any of the information for a retrieved provider needs to be updated, you will need

to edit it.

To edit the information for an existing provider

1. Locate the provider on your Favorite Rendering Provider list and click the

Edit link.

The Edit Rendering Provider popup displays, with the selected provider’s

information.

2. Update the provider’s information.

3. Click





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Removing a Rendering Provider

If you are attempting to add a rendering provider to your favorites, but you are

already at your maximum of twenty favorites, a popup displays. It states, “The

maximum number of Favorites has been reached. Only 20 Favorites may be

designated.”

To remove the popup, click

Note: You will need to remove a rendering provider from your existing

Favorites before you will be able to add another rendering provider

to your Favorites list.

Note: You are able to remove rendering providers from your Favorites list

at any time, regardless of whether you have reached your limit of

twenty favorite rendering providers.

To remove a provider from your favorites:

1. On your list of My Favorite Rendering Providers, locate the provider to be

removed.





09/13/2011

2. Click the Remove link.

A popup displays, stating: “Do you want to delete this provider from your

Favorites?”

3. To remove the favorite provider from your favorites list, click

or

To keep the favorite provider on your favorites list, click

Once you click Yes, the provider is removed from your list of Favorite

Rendering Providers.

You are now able to add an additional provider to your favorites.





2-63

Changing Your Password (Providers and Agents)

To view or edit your password information:


The Settings page opens in the work area. (Shown is Provider view.)


or

Click My Information

The My Information page displays.

Changing Your Password (Providers and Agents)




09/13/2011

The example shown below is for a provider.

The example shown below is for an agent.

3. Click the Change Password link.

The Change Password page displays.





2-65

4. In the Old Password field, type your old password.

5. In the New Password field, type your new password.

Note: Your password must be at least six characters long. It cannot match

any of the five previous passwords used. It must contain at least:

One upper case alpha character

One lower case alpha character

One number

One special character

6. In the Retype New Password field, retype your new password.

7. Click

The Change Password confirmation popup displays.

8. To exit the popup and confirm the password change, click

Note: Changing the password and changing the secret question/answer are

the only My Information fields that an Agent with Office Manager

privileges is not able to manage for their providers.

Prior Authorizations




3-1

Initiating a Prior Authorization Request

Step 1: Search for Patient ..............................................................................3-3

Step 2: Select Patient .....................................................................................3-7

Step 3: Search for Drugs/Services ................................................................3-9

a. Drug Search .....................................................................................3-9

b. Service Search .................................................................................. 3-11

Step 4: Step Therapy Alternatives .................................................................3-12

Step 5: Additional Information.......................................................................3-14

a. Template for Drug Covered Under Medical Benefit.......................3-14

b. Template for Drug Covered Under Pharmacy Benefit....................3-16

c. Educational/Recommended Alternatives .......................................3-17

d. Drugs with Multiple Durations .......................................................3-18

Step 6: Select a Site of Care ...........................................................................3-20

a. Benefit Type ....................................................................................3-20

b. Site of Care ......................................................................................3-21

Step 7: Verify Prescribing Physician or Nurse Practitioner .........................3-21

a. Prescriber View ................................................................................3-22

b. Prescriber’s Agent View ..................................................................3-23

c. Provider/Providing Facility/Provider Agent View...........................3-23

Step 8: Select Rendering Provider .................................................................3-25

a. Add/Search for a New Provider .......................................................3-25

b. Pick from Favorite Rendering Provider List ...................................3-26

c. Lowest Cost Vial Selection ..............................................................3-31

d. Requesting Associated Service Prior Authorizations ......................3-31

e. Duplicate Prior Authorization Notification .....................................3-32

Step 9: Complete Questionnaire ....................................................................3-33

a. Printing clinical questionnaire .........................................................3-35

Step 10: Attach Supporting Documents.........................................................3-36

a. Barcoded fax cover sheet .................................................................3-38

Step 11: Review Submitted ...........................................................................3-39

Complete an existing Prior Authorization Request

a. Get Next PA in Queue ....................................................................3-42

Search for a Previously Submitted Prior Authorization Request

a. To Search for a previously submitted PA .....................................3-44

b. Withdraw a PA ..............................................................................3-47

c. Copy & Update PA ........................................................................3-49

d. Appeal ............................................................................................3-50

Contents




10/7/2011

Initiating a Prior Authorization Renewal

Step 1: Search for a Prior Authorization eligible for renewal ......................3-52

Step 2: Initiate Renewal .................................................................................3-53

Updating Rendering Provider NPI

a. From an email link ...........................................................................3-56

b. Editing the Provider .........................................................................3-57

c. Picking from Favorites ....................................................................3-59

Searching for a Rendering Provider ...............................................................3-61

Adding a New Provider ...................................................................................3-63

Updating Rendering Provider from a Prior Approval ....................................3-64

Blue Cross Blue Shield of Massachusetts (BCBSMA) Providers ONLY

Step 1: Search for Patient ..............................................................................3-66

Step 2: Select Patient .....................................................................................3-67

Step 3: Search and Select drugs or ancillary services ......................................3-68

a. Search for specific drug by NDC, Drug Name, HCPCS/CPT code.....3-70

Step 4: Formulary/Preferred Alternatives ........................................................3-74

Step 5: Additional Information .......................................................................3-74

a. Select Drug/ Service section ...............................................................3-75

Step 6: Select a Dispensing Location ……………………………………….3-77

Step 7: Verify Prescribing Physician or Nurse Practitioner ............................3-78

Step 8: Select the Rendering Provider ............................................................3-80

a. Duplicate Prior Authorizations- Medical Benefit.................................3-81





3-3


To begin initiating a new prior authorization:


2. Click on the Initiate a new Prior Authorization request link

or

Click the Go button for ―Initiate a new Prior Authorization request‖ from

the Home page.





09/26/2011

There are ten steps to initiate a new prior authorization request for a

drug/service covered under the medical benefit (only ten steps for a drug

covered under the pharmacy benefit. These steps display on the left side of

the page.





09/26/2011

The Step 1: Search for a Patient form displays in the work area. On the left side of

the page, your initiation progress is tracked.

1. To view available health plan choices, click the Select Insurance dropdown arrow.

2. To select the patient’s health plan from those displayed on the Insurance List dropdown,

click on the desired health plan. This is a required field.

You may locate the patient one of two ways: Member ID or Name and Date of Birth.

To locate a patient by member ID:

In the Member ID field, type the member ID found on the patient’s insurance card.

Note: Depending on the health plan, you may need to search by the pharmacy benefit

member ID, medical benefit member ID, or either the pharmacy or medical

member ID.

To locate a patient by name (First Name, Last Name and Date of Birth are all required name

search fields.):

1. In the Last Name field, type the patient’s last name. Press Tab.

2. In the First Name field, type the patient’s first name. (The first three letters of the

patient’s first name are required, unless their first name is only two letters). Press Tab.

Next to the Date of Birth Field, the Calendar feature becomes available.





3-7

3. Select the appropriate date from the Calendar feature

or

To bypass the calendar, press Tab again.

4. In the Date of Birth field, type the birth date of the patient as MM/DD/YYYY.

Note: You do not need to enter separators. ExpressPAth will supply the separator

between date fields for you.

5. Click Step 2: Patient Search Results displays in the work area.





09/26/2011

1. Confirm that the patient has active Pharmacy and/or Medical Eligibility (depending on

the health plan).

If the patient does not have active Pharmacy or Medical Eligibility (depending on the

health plan), do not proceed. Contact the health plan to confirm eligibility.

2. If the patient has Pharmacy and/or Medical Eligibility Status of Eligible (depending on

the health plan), click on the patient’s name, which is a hyperlink.

Note: Some patients may be covered by multiple groups under the same health plan. If

the Coverage/Group Number field says ―Select‖ in the dropdown, you will need to select

the appropriate group coverage as well before clicking on the hyperlink of the patient’s

name.

Note: When searching for a patient by Member ID, an entire family may appear in Step

2: Patient Search Results. Make sure that you scroll down, if necessary, and select the

appropriate patient by clicking on the hyperlink with the patient’s name before

proceeding.





3-9

Step 3: Search and select drugs or ancillary services displays.

1. In the Search for Drug by NDC, Drug Name or HCPCS/CPT Code section, in the

appropriate fields type the desired drug NDC number, Drug Name, or HCPCS/CPT code.

Note: Only one drug or service may be entered on a Prior Authorization at a time.

Definition: HCPCS Codes, Healthcare Common Procedure Coding System numbers, are the

codes used by Medicare and monitored by CMS, the Centers for Medicare and Medicaid

Services. They are based on the CPT codes (Current Procedural Technology codes)

developed by the American Medical Association. HCPCS Codes are numbers assigned to

every task and service a medical practitioner may provide to a Medicare patient including

medical, surgical and diagnostic services. There are two sets of codes. The first set, HCPCS

Level I, are based on and identical to CPT codes. Level II HCPCS codes are used by medical

suppliers other than physicians, such as ambulance services or durable medical equipment.

Definition: CPT Codes are numbers assigned to every task and service a medical practitioner

may provide to a patient including medical, surgical and diagnostic services. They are then

used by insurers to determine the amount of reimbursement that a practitioner will receive by

an insurer. CPT codes are developed, maintained and copyrighted by the AMA (American

Medical Association). As the practice of healthcare changes, new codes are developed for new

services, current codes may be revised and old, unused codes are discarded. These codes are

updated annually.





09/26/2011

To search for the desired drug NDC:

1. In the NDC field, type the NDC of the drug, Click Search.

To search for a drug by Drug Name:

1. In the Drug Name field, type the name of the drug, Click Search

To search by HCPCS/CPT code:

1. In the HCPCS/CPT code field, type the HCPCS/CPT code, Click Search.

The Search Results pop-up displays. The Search Results list every NDC available in both the

First Data Bank (FDB) and Medi-Span databases when a search is performed by drug name. If

you had performed the search by HCPCS/CPT or NDC, only those results would appear in the

pop-up.





3-11

3. Click on the desired result, which is a hyperlink. (Shown above is the Drug Name link

result).

If this prior authorization request is for a stand-alone service, you will need to conduct a search in

the Search for Services section.

Definition: Ancillary services fall into three broad categories: Diagnostic, Therapeutic and

Custodial. They are located mainly in three types of facilities: hospitals, medical offices and

free-standing sites. States have regulations concerned with ancillary service providers and their

equipment. They determine what medical direction, consultation and supervision is necessary.

An ancillary service provider extends and facilitates the primary care provided by doctors and

nurses.

1. In the Search for Services section, click the Select a Service dropdown arrow to view

available services for the patient’s health plan.

2. Click to select the desired service option from those listed. Click the Add button. Click

Next to proceed.





09/26/2011

The drug or service you selected displays. Click the Edit Drug hyperlink to make a

change. You will be taken back to the beginning of Step 3 and will need to enter a new

drug or service.

After the drug or service is selected, the Episode of Coverage (EOC) ID is created.

An EOC (Episode of Coverage) is the unique ID number generated by the ExpressPAth

Provider Portal when a user has entered the patient and drug information on a prior

authorization request.

At this point, the user can save the PA at any point and return to complete it, starting at

the step where they last left off within the prior authorization, within five business days.

Clicking Next will automatically save the prior authorization after each step is

completed as well.

If the selected health plan has step therapy in place, Step 4: Step Therapy Alternatives

displays.

Definition: Step Therapy is the practice of beginning medication for a medical condition with

the most cost-effective and safest drug therapy and progressing to other more costly or risky

therapies only if necessary.

While creating a PA, if the selected drug has a step therapy alternative, then the system

will display all the preferred drugs under the Step 4 Step Therapy Alternatives.





3-13

1. The user will click on (one of) the preferred medication(s) and click Next

2. Click on the hyperlink to the appropriate NDC. The Search Results list every NDC

available in both the First DataBank (FDB) and Medi-Span databases.

3. The system will direct the User to the end of Step 3 (Search for Drugs/Services) with the

new preferred Step Therapy medication, Click Next.

Note: If the health plan does not have any step therapy alternatives available in ExpressPAth, this

step is skipped.





09/26/2011

Step 5: Additional Information displays in the work area.

For drugs typically covered under the medical benefit and prescribed with a doctor’s

order, you will see a screen similar to the one below:

To complete Step 5: Additional Information for drugs typically covered under the medical

benefit (actual fields presented to the user may vary because it is based on the information that a

client requests for a drug):

1. Enter the Dosage. A drug dose is the specific amount of medication to be taken per the

frequency. Type the valid dosage in numeric format and select the applicable dosage

(mg, mcg, units, ml, etc.) from the dropdown.

2. Enter the Frequency. Frequency is the number of times a drug is given during a

specified timeframe. Type the valid frequency in numeric format and select the

applicable frequency (hour, week, day, month, year) from the dropdown.

3. The Duration is auto-calculated. Duration is the number of days that a prior

authorization is effective.

a. Example Doctor’s Order: Synagis 15 mg/kg every month for five months (10 kg

baby)

i. Dosage = 150 mg

ii. Frequency = 1 per month (every 28 days)

iii. Duration = 140 days (five months)

4. Quantity is a required field and will auto-calculate based on the information in the

Dosage, Frequency and Duration fields. Quantity refers to the number of NDC units

(e.g., vials, syringes, etc.) prescribed for the specific drug/dosage selected. The quantity

of NDC units will return the number needed for the entire duration.





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5. In the Route field, click the dropdown arrow to select the route of administration of the

drug. The default for this required field comes from Medi-Span. Medi-Span is a

leading provider of drug information, providing drug databases in a variety of formats,

including clinical decision support and disease suite modules. The Medi-Span internal

database is updated daily to include the latest additions and changes being reported by

the FDA, pharmaceutical manufacturers, as well as the latest research articles being

published. You can visit their website at https://medi-span.com/

6. Strength is not an editable field and is populated based on the drug NDC selected.

7. You can indicate whether the prior authorization request is a new or ongoing request in

the New/On-going field.

8. Package Size is not an editable field and is populated based on the drug NDC selected.

9. In the Start Date field, type the start date of service as MMDDYYYY or use the

calendar feature. The Start Date of Service defaults to the current date, but should be

changed to the first date of service, if necessary.

10. The End Date is auto-calculated based on the duration of the prior authorization request.

Editing the end date changes the duration and vice versa.

11. Some ExpressPAth clients (health plans) use our measurement based dosing feature,

which allows them to display a message to the user if the dosage is not appropriate based

on the weight of the patient. The following message will display:

If the drug requires measurement-based dosing, the Patient’s Weight field will appear and

will be a required field. If necessary, type the Patient’s Weight in the Weight field. You

can either enter the weight in Lbs/Oz or in Kgs. Select the method of entry from the

dropdown.

12. The Patient’s Age is auto-populated from the member’s date of birth.

13. Waste Quantity is the portion of a vial that a physician must waste (throw away) after

delivering medication to a patient. This is typically not a required field.

14. Direction is equivalent to the sig line on a prescription or doctor’s order.

15. The Urgency flag can be used to indicate whether a prior authorization request needs

attention faster than the health plan’s standard turnaround time.

In addition to the fields typically visible on the Additional Information screen listed above,

certain drugs may require other information, such as:

Patient’s Height – information can be entered in either feet/inches or centimeters.

Choose the method of entry from the dropdown.

CrCl Level – the volume of blood plasma that is cleared of creatinine per unit time and is

a useful measure for approximating the GFR (Glomerular Filtration Rate), which

describes the flow rate of filtered fluid through the kidney.

https://medi-span.com/





09/26/2011

Body Surface Area- This is a calculated field derived by what has been entered for

the member’s height and weight.

For drugs typically covered under the pharmacy benefit and written as a prescription, you will see

a screen similar to the one below:

To complete Step 5: Additional Information for drugs typically covered under the pharmacy

benefit:

1. Quantity is a required field and refers to the number of NDC units prescribed

for the specific drug/dosage selected.

2. Day’s Supply is a required field and is the number of days that the patient

should take their prescription based on the Quantity prescribed and Direction.

3. No of Refills is the number of refills being requested. If no refills are

authorized, enter zero in this field.

4. Duration will auto-calculate based on the Day’s Supply and No of Refills.

5. In the Start Date field, type the start date as MMDDYYYY or use the calendar

feature. The Start Date of Service defaults to the current date, but should be

changed to the first date that the patient should take the drug, if necessary.

6. The End Date is auto-calculated based on the duration of the prior

authorization request, Editing the end date changes the duration and vice versa.

7. In the Route field, click the dropdown arrow to select the route of

administration of the drug. The default for this required field comes from

Medi-Span. Medi-Span is a leading provider of drug information, providing

drug databases in a variety of formats, including clinical decision support and

disease suite modules. The Medi-Span internal database is updated daily to

include the latest additions and changes being reported by the FDA,





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pharmaceutical manufacturers as well as the latest research articles being

published. You can visit their website at https://medi-span.com/

8. Indicate whether the prior authorization request is a new or ongoing request in

the New/On-going field.

9. Direction is equivalent to the sig line on a prescription or doctor’s order.

10. The Urgency flag can be used to indicate whether a prior authorization request

needs attention faster than the health plan’s standard turnaround time.

Click

Educational/ Recommended Alternative-is a general recommendation to switch to an

alternative therapy that is clinically supported. However, not choosing the

educational/recommended alternative would not result in a Denial.

When a PA is being created for a drug that has an Educational/ Recommended

Alternative, the Alternatives will be displayed at the bottom of the Additional Information

Screen.

1. User will select the preferred Educational/ Recommended Alternative by clicking on the

hyperlink for the drug/dosage and Click Next.

https://medi-span.com/





09/26/2011

2. Click on the appropriate NDC. The Search Results list every NDC available in both the

First Data Bank (FDB) and Medi-Span databases.

3. The system will direct the user back to the end of Step 3 Search for Drugs/Services

screen with the new preferred Educational/ Recommended Alternative medication listed.

Click Next.

4. The system will return the User to the Step 5 Additional Information screen with the new

Educational/ Recommended Alternative medication in place.

5. Complete the Step 5 process again for the educational/recommended drug and Click

Next.

Multiple Durations- Some drugs that are reviewed in Express PAth will have the ability to enter

multiple durations in the additional information screen. This capability allows a user to enter

different dose, frequency and duration combination on a single PA for a single drug. This

functionality allows for situations where a loading dose is required or where the standard course

of treatment includes different doses based on a standardized interval.





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Based on the Drug Selected and Diagnosis code entered in Step 3, the Multiple Durations

display will populate in the Step 5 Additional Information Tab.

1. Enter Frequency- (frequency is the number of times a drug is given during a specified

timeframe). Type the valid frequency in numeric format.

2. Select the applicable Frequency in the dropdown box.

Example: Doctor’s Order: Synagis 15 mg/kg every month for five months

(10 kg infant)

I. Dosage= 150 mg

II. Frequency= 1 per month (every 28 days)

III. Duration= 140 days (five months)

3. Enter the Dosage- (the specific amount of medication to take per frequency). The dosage

should be based on the frequency requested not the duration requested. Type the valid dosage in

numeric format.

4. Select the applicable Dosage type in the dropdown box.

Example: If the patient is to be given 150 mg every 28 days, ―150 mg‖ is the

dosage that should be entered.





09/26/2011

5. Enter the Start and End Date for each Duration on the screen. Durations cannot have

overlapping date spans and the application will not allow the Dosage and Frequency to be equal

for consecutive durations.

6. If the Multiple Duration section requests the patient’s weight, please fill out appropriately.

7. Click Next Step to submit the Multiple Duration information.

Step 6: Select a Site of Care displays. You must select the benefit type and site of care where

the drug will be administered from the dropdown.

To select a Benefit Type:

1. In the Benefit Type field, click the dropdown arrow.

2. Select the appropriate Benefit Type. The field requires the selection of either

Pharmacy of Medical benefit. If the member has one Benefit Type (ex: medical),

only that benefit will populate in the field.

Once the Benefit Type has been selected, the Site of Care will populate.





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To select the Site of Care:

1. In the Site of Care field, click the dropdown arrow.

If the Pharmacy Benefit is chosen, Retail Pharmacy will be displayed in the Site of

Care Field.

If the Medical Benefit is chosen, Site of Care location values will be displayed in the

Site of Care Field.

2. Select the appropriate Site of Care, Click Next.

Step 7: Verify Prescribing Physician or Nurse Practitioner displays in the work area.

The Prescribing Physician is a person who is licensed to write a prescription for a drug

or service (e.g. Physician, Nurse Practitioner, Physician's Assistant or a Pharmacist). For

the purpose of the PA request, this is the physician that prescribed the medication that is

being requested.





09/26/2011

There are several ways to populate Step 7: Verify Prescribing Physician or Nurse

Practitioner.

Prescribing Physician View

If you are logged in as the prescribing physician, your primary practice location information will

automatically appear on this screen. Simply click on this screen if none of the information

has changed. (If you need to permanently change any of the information on this screen, you must

change your profile preferences under the Settings tab.)

To select a different prescribing location than your primary (default) practice location:

1. Click the Select different location of Prescriber dropdown.

2. From the list of associated locations, click on the desired prescriber location to select it.

3. Click





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If you are logged in as an agent of a prescriber, select the appropriate prescriber/practice location

from the dropdown. If the agent is not the prescriber or associated to the prescriber, the email

address is not required. Simply click on this screen if none of the information has changed.

(Your prescriber or his/her associated agent with an Office Manager role can permanently change

any of the information on this screen by updating the prescriber’s profile preferences under the

Settings tab.)

Provider/Providing Facility or Provider/Providing Facility Agent View

Prescribing Agent View





09/26/2011

If you are logged in as a provider, providing facility or one of their designated agents, you have a

few options on this screen.

To manually enter details for the prescriber, click the Add Prescriber link:

1. In the NPI field, type the physician’s NPI number.

The National Provider Identifier (NPI) is a unique identification number for health care

providers issued by the National Plan & Provider Enumeration System (NPPES) that

will be used by all health plans. NPIs are issued to health care providers in order to

submit claims or conduct other transactions specified by HIPAA. Click on the link

below to view/update the NPI or to request a new NPI.

https://nppes.cms.hhs.gov/NPPES/StaticForward.do?forward=static.npistart

Note: The State License ID and DEA fields are optional.

2. In the Taxonomy Code field, type the physician’s taxonomy code number

or

Select the physician’s Specialty from the dropdown list. Once the Specialty or the

Taxonomy Code is selected, the other field auto-populates.

The Health Care Provider Taxonomy codes are national specialty codes used by

providers to identify their specialty category. The codes are created by the National

Uniform Claim Committee (NUCC), which is chaired by the American Medical

Association. Click on the link below to obtain the list of taxonomy codes and to identify

the correct code to use for your specialty.


3. In the First Name field, type the physician’s first name.

Note: The Prefix and Middle Initial fields are optional.

4. In the Last Name field, type the physician’s last name.

5. In the Address Line 1, City, State, and Zip fields, type the physician’s address.

Note: Address Line 2 is optional.

6. In the Work Phone field, type the 10-digit phone number.

Note: Fax information is optional, but should be entered if possible so that the health

plan can fax prior authorization request notifications to the prescriber.

https://nppes.cms.hhs.gov/NPPES/StaticForward.do?forward=static.npistart






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7. In the Enter your Email Address field, type your email address. If you don’t know the

prescriber’s email address, enter a dummy email address here: [email protected].

8. In the Retype Email Address field, type your email address again. The two email

addresses must match.

9. To save the changes, click

10. To continue to the next step, click

Step 8: Select/Change/Edit Rendering Provider displays in the work area.

A Rendering Provider is any person or facility that is licensed to administer a drug or

service (e.g. Physician’s Office, Home Infusion Therapy Agency, Specialty Pharmacy,

Outpatient Facility or a Dialysis Center). For the purpose of the PA request, this is the

facility that will be administering the drug or service requested in the prior authorization

for a drug covered under the medical benefit.





09/26/2011

The Select/Change/Edit Rendering Provider page determines if this request will be

submitted using the prescriber’s NPI or using a different NPI.

In the Options section there are several options:

Leave the provider as listed (using the prescriber’s NPI)

Select a different location for the prescriber

Search for a different provider

If the provider is not available by search, Add a new provider

Pick a provider from your Favorites List

To use the prescriber’s NPI and primary location to submit this claim, click

To select a different location for the prescriber, click the radio button Select Different Location

and choose the alternate location from the dropdown that appears.

Picking a different Rendering Provider

To use a different NPI number to submit this claim:

1. In the Options section, select the Add/Search for a different Provider radio button.

2. The Add Provider and Search Provider links become available.





3-27

To Search for a different rendering provider:

1. Click

The Search Rendering Provider form displays at the bottom of the work area.

2. Search for an existing rendering provider one of three ways:

By NPI number,

or

By First Name and Last Name,

or

By Facility Name

3. When you have populated the desired fields, click





09/26/2011

A list of providers matching your search displays in the blue section of the form. A

provider does not have to be registered to use ExpressPAth to be found – most providers that are

registered with CMS should pull in the search results.

4. Scroll to the desired provider, then click the Provider Name link.

The rendering provider’s information displays in the Rendering Provider Details

section.

5. To submit this provider as the rendering provider, click





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To Add a new provider and use this provider as the rendering provider:

1. Click the Add Provider hyperlink.

The Add new Rendering Provider form displays at the bottom of the page

2. In the NPI field, type the provider’s NPI number.

3. Click the Specialty field dropdown to select the provider’s specialty. Selecting the

Specialty will auto-populate the Taxonomy Code field.

a. or

b. In the Taxonomy Code field, type the provider’s taxonomy code number. This

will auto-populate the Specialty field.

4. The Facility Name field is optional.

5. The First Name, Last Name, Address Line 1, City, State, Zip, and Work Phone

number fields are required and must be populated.

6. The Prefix, Address Line 2, Fax #1 and Fax #2 fields are optional; however, a fax

number should be entered in the Fax #1 field, if possible, so that prior authorization

notifications can be sent from the health plan to the provider.





09/26/2011

7. In the Enter your Email Address field, type the provider’s email address. If you don’t

know the provider’s email address, type in a dummy email address: [email protected]. If

you are not the prescriber or not associated to the prescriber, the email address is not

required.

8. In the Retype Email Address field, type the provider’s email address again. The two

email addresses must match.

9. When finished, click

You can add any provider to your list of favorite rendering providers by simply clicking on the

checkbox at the bottom of the screen on Step 8

Up to twenty favorite rendering providers can be saved in your profile.

To select a different rendering provider from your list of Favorites:

1. Click the Pick Provider from Favorites List radio button.

2. A dropdown selection box displays to the right of this choice.

3. To view the favorites, click the dropdown arrow.

4. If providers on your favorites list are available to be rendering providers for this patient,

they will display on the list.

5. Click the provider to select it.


Step 8: Select Rendering Provider redisplays, with your provider’s information in the

detail section.







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Lowest Cost Vial- a service that replaces the requested Drug (NDC) with the most cost

effective UM Managed NDC. Users are able to choose the Lowest Cost Vial or opt out of

the recommended drug.

The Lowest Cost Vial functionality can be enabled by a health plan – it is not

presented to the user unless the health plan requests the user to choose the lowest cost

vial health plan

If a drug has the Lowest Cost Vial option for a health plan, the following message will appear

after the user Clicks Next Step in Step 8: Lowest Cost Vial (Click on the radio button to

select any lowest cost vial).

If the User’s original request is for the Lowest Cost Vial already, the pop-up will not

populate.

1. User will click on the appropriate Radio Button and Click Next

2. If the Pop-up box displays more than one option, the User must choose an option

and Click Next.

Once the drug is chosen and the user Clicks Next, the system will direct to Step 9

Complete the Questionnaire.

Drug/ Service Association: ExpressPAth can associate a set of services with a drug and

automatically create related prior authorizations for each of the services that have been associated

to that drug. A list of drugs and possible related services are configured into ExpressPAth by a

health plan. If the user has requested a drug that has services available, the following steps will

occur.





09/26/2011

1. User will click the Next Step button to submit Step 8 and will receive the following

message:

The following ancillary service(s) will be requested upon submitting this PA.

Please enter a quantity if applicable and make a choice if more than one option

exists.

User will enter the correct quantity and select the correct Service Set Radio button

More than one Service may populate, please choose the appropriate set

Quantity is a required field and will default to 1, if not entered.

2. Click Save and the system will direct User to Step 9.

Duplicate Error Message: will populate when the Portal User is creating an EOC under the

Medical Benefit for a Prior Authorization that already exists. The message will appear if the User

is creating an EOC with the same Patient, Drug, Provider and overlapping time periods.

1. User will submit information in Step 8 by clicking Next Step, the following error message

will populate: ―You are attempting to create a PA for a patient, drug, and provider that

already exists.‖





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2. Click View to view the existing PA.

3. Click Ok to exit out of the message and discontinue the request.

Step 9: Complete all the sections in the form below displays in the work area

Click the Answer hyperlink to answer the clinical questionnaire.





09/26/2011

.

The clinical questionnaire displayed in Step 9 must be completed before the prior

authorization can be completed. The responses are based on the clinical policies of the

health plan. All enabled questions require an answer.

Depending upon the responses given to previous questions, the questionnaire will enable

or disable (grey out) the appropriate questions.

If any additional clarification is needed, Help Icons are available as a reference. These

icons are Questions Marks found throughout the questionnaire. The User can hover over

the icon for reference information.





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If the user does not have all of the clinical information that they need to complete the clinical

questionnaire, they can click the Print hyperlink.

Clicking the Print hyperlink brings up a PDF of the fax form with all of the clinical questions.

Questions that were already answered by the user will show the answers already given. Questions

that have not been answered yet will all be enabled.

The user can then click the Save button to save the questionnaire and come back to it within five

days to complete it. If they do not come back to complete the prior authorization within five

days, the EOC will be automatically withdrawn and the user will have to start a new prior

authorization request. When the user is ready to complete the questionnaire, they will be brought

to Step 9 in the process and will click the Edit Answers link.

2. Once the clinical questionnaire is completed, click

If an answer is missed, the following prompt displays.

3. To continue, click and proceed to Step 10.

or

Click Cancel and return to the clinical questionnaire to complete the missed questions.

4. Complete any unanswered questions and click





09/26/2011

Step10: Attach any supporting documents displays in the work area.

Attaching Supporting Documentation

Attaching Supporting Documentation is an easy process.

The files that are uploaded into ExpressPAth must be in one of the following formats.

PDF -- Used for both images and text

BMP -- Used primarily for images

GIF -- Used primarily for images

JPG -- Used primarily for images with photographic images requiring high-color

resolution

TIFF -- Used for images that span multiple pages

DOC - Microsoft Word 1997-2003— Used primarily for text

DOCX - Microsoft Word 2007—Used primarily for text

IMPORTANT: Individual file size cannot

exceed 4 MB each.





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To attach a document:

1. To locate the document, in the Select file field, click .

2. Locate the file on your computer then select the document by clicking on it.

3. Click the Open button.

The file displays in the Select file field.

4. In the Description field, enter an appropriate description for the file.

5. In the Document Type field, click the dropdown arrow and select the correct

description for the file document type.





09/26/2011

6. Click .

A summary of the attachments displays.

7. In the Comments and Additional Supporting Information freeform text box, enter

your comments or any additional information.

If you are unable to upload or scan information, Click the ―here‖ link to obtain a Barcoded fax cover sheet.

This cover sheet is barcoded for the health plan, when faxed; the information will be attached to the EOC.

8. When all files are attached, click





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Step 11: Review Submitted

A notification message indicates your answers will be submitted and you will be unable

to make changes.

9. To proceed and submit, click Yes.

Depending on the health plan and if all clinical criteria have been answered according to

the health plan’s policy, you may see an automatic approval, as shown below.

Complete PA Form redisplays with an Approved link to the PA request.

The health plan’s policy may require that the authorization be submitted to the health

plan for further clinical review.





09/26/2011

After the submission, a link is included to check the status of a submitted PA request.

The User will have three additional options that appear on the bottom of the screen after

the submission of a request:

1. Home- to return to the ExpressPAth landing page click

2. Additional PA- to request another PA for this patient, using the same

Demographics

click

3. Search PA’s- to check the status of previously submitted PA click





3-41

Completing an existing Prior Authorization Request

A prior authorization (PA) that was not completed immediately after initiation may be completed

within ten calendar days by clicking on the Complete existing Prior Authorization requests link

on the Prior Authorization Portal.

The Complete Prior Authorization page displays in the work area.

Completing an existing Prior Authorization Request




09/26/2011

This accesses the Open (or incomplete) prior authorization requests. If there are prior

authorization requests that need to be completed within ten days of the date initiated, a

message displays indicating the number of PA’s to be completed.

Note: An Open PA that has been initiated but not completed within ten days will be

removed from ExpressPAth.

To complete the next prior authorization request in your queue:

1. Click the Get Next PA in Queue link.

The prior authorization opens at the point where it requires attention.

2. Continue to complete the prior authorization.

To filter by patient to locate a prior authorization request:

1. Click the Filter by Patient link.

Step 1: Search by Patient Details displays in the work area.

2. To Search for the patient, at least one of the following fields is required:

First Name, Last Name, Date of Birth, Member/Insurance No., Group Number.

If you are an agent, you also must choose the appropriate prescriber/provider from the

Physician/Nurse dropdown.





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To search for a Prior Authorization started between a date ranges, enter the dates in the

Prior Authorization Start Date between fields.

3. Click

Search Results display in the work area.

4. To continue, click either the Complete PA link or the hyperlink of the patient’s name.

5. ExpressPAth will automatically take you to the first screen where you need to enter

information in order to complete the prior authorization request.

Checking the Status of a Previously Submitted PA Request




09/26/2011


To check the status of a previously submitted (complete) prior authorization request, on the Home

page:

1. Click on the Search for a previously submitted Prior Authorization request link

or

Click .

To search for a previously submitted prior authorization request:





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1. Populate at least one of the fields indicated by a red identifier at the field end. If you are

an agent of a prescriber or providing facility, you must select the prescriber or provider

of the PA from the Physician dropdown menu.

Populating more fields with specific information filters the search results. For example,

if you know the patient’s member ID or Prior Auth (EOC) ID, the results will be specific

to your search

2. To search for a Prior Authorization started between a date range, enter the dates in the

Prior Authorization Start Date between fields.

3. To begin the search, click

Step 2: Search Results – Click on patient name (OR) Status to view details displays beneath

the original search.

1. To view details of the desired prior authorization, click the Patient Name hyperlink or the

Status hyperlink.

Note that related prior authorizations appear together in the search results and are

outlined with a





09/26/2011

If the status is Approved, you will see the screen below. The top section under Step 3: Prior

Authorization Status reflects the information requested. The bottom section, Authorized Drug

Details, reflects the approved prior authorization parameters.

Search results could also show a status of Denied or In Progress. Depending on the

status reflected, several other options are available to the user. These options include:

Withdraw, Copy & Update PA, Update NPI, Appeal or Renew.

Initiating an Appeal




09/26/2011

Withdrawing a Prior Authorization

A user may withdraw a prior authorization request after a prior authorization has been submitted,

but while the decision status is still In Progress. This may be necessary if an error was made and

noted after submission of the request.

To withdraw a prior authorization:

1. Go to the Search for a previously submitted Prior Authorization request link.

2. Search by EOC, patient name or other search criteria, as previously mentioned.

3. Locate the appropriate EOC with status of In Progress

4. Click the Withdraw hyperlink.





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A popup box displays with the EOC ID of the prior authorization and the name of the patient.

4. If you want the prior authorization to be removed and no longer accessible, in the popup

box, click Yes.

The prior authorization no longer displays in your Search for previously submitted

Prior Authorization requests list.





09/26/2011

Copying and Updating a Prior Authorization

ExpressPAth has a Copy & Update PA feature for prior authorization requests that saves time

when additional PA requests are needed for the same patient.

To start the copy and update process:



3. Locate the appropriate EOC with status of Approved

Search Results display beneath the search criteria.

The Copy & Update PA link displays in the upper right corner of the search results

Copy and Update is designed as a shortcut for creating a PA request for the same

patient. It allows you to change any of the information except the patient’s member

profile.

1. Click Copy & Update PA hyperlink of the desired patient.

A popup displays to remind you that a copy of this prior authorization will be created.

Click Yes.

You will be taken to Step 3: Select Drug/Service. From here, you can begin to enter details about the new request, such as the drug/service, additional information, prescriber and clinical questions. Please refer to the Initiate a Prior Authorization Section, beginning on page 9.Initiating an Appeal (Select Clients ONLY)

If a prior authorization is in Denied status, an appeal request may be submitted to have the denial

re-evaluated. ExpressPAth supports up to five levels of Appeals.





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NOTE: Appeals are not supported by ExpressPAth for every health plan. If you do not see an

Appeal link for your member on a Denied EOC request, please contact your health plan directly

to process an appeal.

To begin the appeal process:



3. Locate the appropriate EOC with status of Denied

4. To appeal this status, click

To view more information about the EOC prior to initiating an appeal, you can click on either

the Patient Name hyperlink or the Denied Status link. This will take you to the EOC

details screen, where you can view the Outcome Explanations and a copy of the

notification sent to the prescriber. If you still wish to make an appeal after viewing the

details, you can click the link to Appeal this Request.





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The Initiate an Appeal Request page displays in the work area, with the details of the

PA.

7. Review the details of the prior authorization.

8. Enter any comments or additional information related to this prior authorization request

and/or attach any additional supporting documentation (see Initiating a Prior

Authorization Request – Step 10: Attaching Supporting Documentation on page 36 of

this user guide).

9. Click

A message indicates you have successfully initiated an appeal request.

10. Click





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A prior authorization which will expire in 90 days or less may be renewed one of two ways: 1)

Click on the Renew a Prior Authorization Request link 2) Click Search for a previously submitted

Prior Authorization request and locate an approved EOC that has a Renew link.

To begin the PA renewal process by using the Renew a Prior Authorization request link:

1. On the Prior Authorization Portal for Physicians page, click the Renew a Prior

Authorization request hyperlink

or

Click .

Step 1: Search for Prior Authorizations eligible for renewal displays, with PA’s

expiring in the next 90 days displays. This is the default.





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1. You can conduct a search, as discussed in the Search for a previously submitted Prior

Authorization request section. Once the EOC displays in the Search Results below,

click the link.

Step 2: Initiate Renewal displays in the work area.





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3. Review the Renewal Request fields for this prior authorization. Several fields are

editable, and can be updated if necessary.

4. Enter comments or additional information, if needed.

5. Click

A message displays to confirm that you have successfully initiated a renewal request.

6. Click

A renewal may have no clinical questions, a different set of clinical questions than the initial

request, or the same questions as the original request. This is dependent upon the health plan’s

benefit set-up.

Complete the clinical questionnaire and attach any supporting documentation (if necessary).

Refer to Steps 9 and 10 of Initiating a Prior Authorization Request starting on page 33 for

instructions.





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If the rendering provider information on a submitted claim does not match the rendering provider

information on the prior authorization, the claim rejects.

If this happens, providers and agents associated to the approved authorization may receive an

email from the member’s health plan, requesting an NPI update. The link in the email brings the

authorized users to the authorization in ExpressPAth that requires the update. The authorized

users then have the ability to update the rendering provider NPI so that claims submitted using the

authorization will process appropriately.

Another way to update the rendering provider NPI is to locate the episode of coverage (EOC). If

the status of the EOC is ―Approved‖ and the health plan has requested that users associated to the

prior authorization in ExpressPAth update the NPI, an Update NPI link displays. After clicking

the Update NPI hyperlink, the prior authorization page displays the current rendering provider

information and contains links to change the rendering provider.

Updating Rendering Provider from an Email Link

If you have received an email requesting an update to the Rendering Provider information, you

are able to begin your update from the email. The email may contain the updated NPI that should

be associated to the rendering provider. If the NPI is not included in the email, you need to

update the NPI to the billing NPI the provider is using on the claim.

To start the Rendering Provider NPI Update from the email link:

1. Click the link embedded in the text of the NPI update email.

Note: If the EOC in question is being used by another ExpressPAth user, you will

receive a message that the record is locked. You will need to wait for the EOC

to be unlocked to make changes to it. You cannot continue at present.

or

If the EOC is available and the Rendering Provider NPI has already been

updated, ExpressPAth will return a message that this information has already

been updated. There is no need to continue.

2. If the EOC is not locked and the Rendering Provider NPI has not been updated, log into

the ExpressPAth Portal after clicking the hyperlink in the Update NPI email.





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ExpressPAth displays the previously submitted prior authorization request requiring an

NPI update.

Current Rendering Provider Information is shown, including NPI information.

Note: If the updated NPI was provided by the member’s health plan, the system returns

the Rendering Provider information, including current and updated NPI

information.

Editing the Provider

To change the NPI by editing the Provider:

1. If the desired Provider displays but the NPI information is incorrect, in the Change

Rendering Provider area click the Edit Provider Link.





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The Edit Rendering Provider box displays.

2. In the NPI field, update the NPI number. Update any other relevant information, if

necessary.

3. Click





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4. The Rendering Provider page redisplays with current and updated NPI information.

5. To update the information, click

ExpressPAth redisplays the page with the updated NPI information.

To cancel the update, click

Picking from Favorites

To change the Rendering Provider by selecting from your Favorite Rendering Providers list:

1. Click the Pick From Favorites link.





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The My Favorite Rendering Provider(s) list displays as a pop-up box.

2. Locate the provider on your My Favorite Provider(s) list.

3. Click the Provider Name link.

The selected favorite rendering provider displays on the Change Rendering Provider

area of the page.





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4. To update the prior authorization with this rendering provider, click

or

To cancel this provider selection, click

If the desired rendering provider is not on your My Favorite Rendering Provider(s) List,

you are able to search for the provider.

Searching for a Rendering Provider

To search for a rendering provider:

1. Click the Search Provider link.

The Search Rendering Provider form displays. You are able to search for an existing

rendering provider using this form.

2. In the NPI field, type the NPI number of the rendering provider.

or

In the First Name and Last Name fields, type the name of the rendering provider.

or

In the Facility Name field, type the name of the rendering facility.

3. Click





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The results of the Rendering Provider search display.

4. To select a rendering provider from the search results for the desired provider, click the

Provider Name link.

The selected rendering provider is displayed in the Change Rendering Provider area of

the page.





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5. To update the prior authorization with this rendering provider’s NPI, click

or


Adding a New Provider

To change the Rendering Provider by adding a provider:1. Click the Add new Provider link.

The Add new Rendering Providerform displays as a pop-up box.

2. You must enter the Provider details in the following required fields, marked with a

red asterisk (*):





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NPI

Specialty

Taxonomy Code

First Name

Last Name

Address Line 1

City

State

Zip

Work Phone

Email address

3. When the required fields are populated, click

The added provider displays in the Change Rendering Provider area of the page.

4. To update the prior authorization with this rendering provider, click

or


Updating Rendering Provider from a Prior Authorization

To start the Rendering Provider NPI update from the Prior Authorization:



3. Locate the appropriate EOC with status of Approved.





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Click the Update NPI link.

The Update previously submitted requests area displays with the current NPI

information for this prior authorization.





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Blue Cross Blue Shield of Massachusetts (BCBSMA) Providers ONLY:

Initiating a Prior Authorization Request for Home Infusion Therapy (HIT)

If a provider is registered as a Specialty Pharmacy, Home Infusion Therapy Agency, or a Dialysis

Center, or an agent thereof, additional HIT drug/service options are available when initiating a

prior authorization.

The Home Infusion Therapy (HIT) categories are most commonly used to initiate a HIT prior


The request process for a HIT prior authorization is the same as a non-HIT request until the 3rd

step.

To initiate a prior authorization request for a home infusion therapy product:

1. On the Prior Authorization tab page, also known as the Prior Authorization Portal for

Physicians, click on the Initiate a new Prior Authorization request link.

or

To the right of this link, click

The Step 1: Search for a Patient form displays in the work area. On the left side of

the page, your initiation progress is tracked.





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2. To view available health plan choices, click the Insurance List dropdown arrow.

3. To select the patient’s health plan from those displayed on the Insurance List

dropdown, click on Blue Cross Blue Shield of Massachusetts (BCBSMA). This is a

required field.

Note: The patient must be a Blue Cross Blue Shield of Massachusetts (BCBSMA)

member and the ExpressPAth user must be registered as a Home Infusion

Therapy Provider, Specialty Pharmacy, Dialysis Center, or agent thereof to enter

a request for a prior authorization using this method.

4. Locate the patient by searching by Member Id

or

Locate by searching with a combination of Last Name, First Name and Date of Birth.

5. Enter the patient search criteria and click

Step 2: Patient Search Results displays.

Note: Based on the search criteria entered, one or more patient eligibility records will

display.

6. If multiple records display, locate the correct patient.





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1. In the Medical Coverage Details section, confirm that the patient has active Medical

Eligibility.

If the patient does not have active Medical Eligibility, do not proceed.

HIT prior authorizations can only be requested for patients with BCBSMA medical

coverage and active eligibility.

2. If the patient has a Medical Eligibility Status of Eligible and is the correct patient, click

on the Patient Name hyperlink.

Step 3: Search and select drugs or ancillary services displays.

If a provider is registered as a user who can perform HIT prior authorizations for

BCBSMA, additional drug/service options are available when initiating a prior

authorization.

To search for a Home Infusion Therapy category,

1. In the Search for Home Infusion Therapy section, click the Select Category dropdown.





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A list of Home Infusion Therapy options available for this client displays.

The Home Infusion Therapy categories are most commonly used to initiate a HIT prior


2. To select a Home Infusion Therapy category for the patient, click on the category.

3. When a category has been selected, click





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A list of drugs included in the selected HIT category displays.

You can also search for a specific drug by NDC, Drug Name, or HCPCS/CPT Code

instead of using the HIT category list.

4. To select the drug you are requesting for the patient, click the drug name.

Drug search results display for the selected drug.

5. Locate the NDC for which you are seeking prior authorization. You may need to scroll

to find it.

6. To add the drug to the request, click on its Drug Name hyperlink.

In the Search and Select drugs or ancillary services section, the selected drug displays

on the Selected Drugs/Services List.





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When initiating a HIT prior authorization request, you have the option to request up to

twelve drugs and/or services on a single request.

The first drug or service selected displays at the top of the form.

To add another drug or service to the request, click

1. Repeat the process for HIT selection to add drugs/services.

The next selection can be from the same category or from a different category.





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2. In the Search for Home Infusion Therapy section, click the Select Category dropdown

arrow.

1. Select the designated category.

2. Click .

3. Search Results display the drugs/services in the selected category.





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6. Locate the NDC for which you are seeking prior authorization. You may need to scroll

to find it.

7. To add the drug to the request, click on its Drug Name hyperlink.

The second drug or service displays in the Selected Drugs/Services List.

Note: When multiple drugs/services are requested, you always have the option to

remove the item from the request.

To remove a drug or service from the request, deselect the checkbox of the item

to be removed.

8. When you have completed additions to the request, click





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If the patient’s benefit design is set for it, Step 4 – Formulary/Preferred Alternatives

displays.

If formulary alternatives are available, you have the option to replace the non-preferred

drug that was selected with a preferred alternative drug.

This step is bypassed when no preferred alternatives are available, depending on the

patient’s benefit design.

If Step 4 does not display or after Formulary Alternative choices have been made, if

appropriate, Step 5- Additional Information displays.

If the request includes multiple drugs/services, you must complete the Additional

Information section for each drug/service.





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To complete Step 5: Additional Information:

1. In the New/On-going field, if this is a new prior authorization request, select New.

or

If this is not a new prior authorization request, select On-going.

2. If you believe that the standard review timeframe may seriously jeopardize the life or

health of the patient or the patient’s ability to regain maximum function, choose Yes in

the Is this an Urgent Request field.

The default for this field is No.

3. To add comments to this request, type your comments in the Comments free-form text

field.

4. To select the method of administration of the drug, in the Selected Drugs/Services

section, click the Route dropdown.





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5. Set the Date fields appropriately. The Start Date defaults to the current date. The End

Date is calculated based on the Duration field.

The Duration field displays a default value based on the product or service selected, but

will automatically re-calculate based on the data entered into the No of Refills and Days

Supply fields.

6. In the appropriate fields, indicate the Quantity and Days Supply instructions for each

drug/service on the HIT prior authorization request.

The Quantity field refers to the total number of units prescribed for the selected

drug/dosage per the indicated Days Supply.

For example: For a drug that is prescribed for 2 tablets per day with a Days Supply of 7

days, you would enter 14 in the Quantity field.

7. Days Supply refers to the total number of days that the supply of medication in the

Quantity field should last the patient for a single fill.

Once the field has re-calculated, you can manually enter the length in days you want the

prior authorization to be valid.

8. In the No. of Refills field, enter the number of refills you are requesting. Do not include

the initial fill.

9. In the Directions field, type specific drug administration directions.

Note: To remove a drug/service from the request, click then click

The deselected drug or service is removed.





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Step 6- Select a Dispensing Location displays in the work area.

The Dispensing Location is the site where the requested drugs/services are

administered.

When requesting a HIT drug/service, the only dispensing location option is Home

Infusion.

Note: Non-HIT providers have additional dispensing location options available to

them.

To select Home Infusion as the Dispensing Location, click





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Step 7- Verify Prescribing Physician or Nurse Practitioner displays in the work area.

A Prescriber is licensed to write a prescription for a drug or service (such as a

Physician, Nurse Practitioner, Physician’s Assistant or a Pharmacist).

In this section, you add the prescriber’s information to the request.

To locate the prescriber’s information, click

The Search Prescriber box displays.





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To search for prescribers:

1. In the NPI field you may type the prescriber’s NPI number

or

You may search by Prescriber First Name and Last Name,

or

You may search by Facility Name.

2. Click Search.

The results of your search display at the bottom of the Search Prescriber box.

You may need to scroll to locate the appropriate prescriber.

Note: If you cannot locate the prescriber’s information, you have the ability to

manually add the prescriber’s information.

3. To add the prescriber to the request, click the Prescriber Name link.





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Step 7: Verify Prescribing Physician or Nurse Practitioner displays with the

prescriber’s details.

4. Click

Step 8: Select the Rendering Provider displays in the work area.

A Rendering Provider is licensed to administer a drug or service (e.g. Physician’s

Office, Home Infusion Therapy Agency, Specialty Pharmacy, Outpatient Facility or a

Dialysis Center).

You may need to select a different provider or location information from the default

display.

Based on your selection, you may need to make changes to the Provider Details

section.

The final 3 steps to complete this HIT request are:

Answer the Clinical Questionnaire

Attach Supporting Documentation

Submit the Prior Authorization request

This process is referred to as ―Completing a Prior Authorization Request.‖





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Duplicate Prior Authorizations – Medical Benefit

A medical prior authorization request is considered a duplicate when a PA already exists for the

same patient, drug classification and overlapping date range (start and end date). ExpressPAth

will not allow you to create a new medical prior authorization request at Step 8 if:

The request is for a prior authorization with the same patient, drug classification and

overlapping date range with a DIFFERENT provider. You will receive this message:

The request is a duplicate of more than one EOC in ExpressPAth (for the same or different

providers). You will receive this message:

If you are trying to create a prior authorization and an EOC for that patient, drug classification

and provider already exists in ExpressPAth, the system will check to see if the original PA end

date is within 90 days of the new PA start date. If it is, the system will check to see if you are

actually trying to create a Renewal. The following screen will display:





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If you are trying to create a Renewal, click Yes. The system will take you to the clinical

questionnaire for the renewal and you can proceed from there.

If you are not attempting to create a Renewal, click No. ExpressPAth will perform an update to

your original PA with the new information.