Surescripts Prior Authorization: A Step-by-Step Guide

What is Surescripts Prior Authorization?

Surescripts' prior authorization is a critical healthcare process that streamlines medication approval through the nation's leading health information network. Surescripts accelerates medication delivery by making prior authorization faster and simpler, delivering approvals in minutes. This comprehensive electronic system connects healthcare providers, pharmacies, and payers to ensure patients receive appropriate, cost-effective medications while maintaining quality care standards.

Understanding the Surescripts prior authorization process is essential for healthcare providers seeking to reduce administrative burden, improve patient outcomes, and enhance practice efficiency. This step-by-step guide will walk you through every aspect of the Surescripts prior authorization system, from basic portal navigation to advanced Touchless Prior Authorization technology.

Understanding Surescripts Electronic Prior Authorization

Electronic Prior Authorization eliminates the inefficiencies and administrative burden of manual processes by automatically sending questions, receiving answers and attachments, sending responses, and initiating renewals. The Surescripts network facilitates seamless communication between all stakeholders in the medication approval process.

Key Benefits of Surescripts Prior Authorization

Time Reduction: In an AHIP study, the median time to a decision decreased 69% compared with manual prior authorization. Healthcare providers can complete authorization requests significantly faster than traditional methods.

Improved Patient Outcomes: Average wait time dropped by more than two days for one health system using Electronic Prior Authorization. Faster approvals mean patients can start their medications sooner, improving treatment adherence and outcomes.

Administrative Efficiency: Providers report finishing 10 electronic prior authorizations in the time it takes to finish one or two manually during a day.

Step-by-Step Guide to Surescripts Prior Authorization

Step 1: Account Registration and Setup

Create Your Prescriber Account

The first step in accessing Surescripts' prior authorization services involves creating a verified prescriber account through the Surescripts Prior Authorization Portal.

Required Information for Registration:

• Provider name and National Provider Identifier (NPI) number
• Practice address and contact information
• Tax identification number
• Provider specialty designation
• Multifactor authentication setup

Identity Verification Process

Healthcare providers must complete identity verification with CLEAR and add location information to ensure secure access to patient data and authorization systems.

Step 2: Portal Navigation and Access

Accessing the Surescripts Prior Authorization Portal

The Surescripts Prior Authorization Portal is a free and easy way for prescribers and their staff to submit and manage prior authorization requests for medications online. Healthcare providers can access the portal through the official Surescripts website or integrated EHR systems.

Dashboard Overview

The portal dashboard provides:

• Real-time status updates for pending authorizations
• Quick access to submit new requests
• Patient eligibility verification tools
• Authorization history and tracking capabilities

Step 3: Submitting Prior Authorization Requests

With the TRX Code Method

When a pharmacy alerts you that prior authorization is needed via fax or an RxChange message, it may include a TRX code. This is an 8-digit code that links information about the patient, prescription, and benefit coverage to your prior authorization request.

Process with TRX Code:

1. Enter the 8-digit TRX code in the portal
2. Verify auto-populated patient and prescription information
3. Complete required clinical documentation
4. Submit the request electronically

Without the TRX Code Method

Healthcare providers can complete prior authorization requests in the portal when they don't have a fax or RxChange message with a TRX code.

Manual Entry Process:

1. Select "New Request" from the dashboard
2. Enter patient demographics and insurance information
3. Input medication details and dosing requirements
4. Provide clinical justification and supporting documentation
5. Submit for review

Step 4: Required Documentation and Information

Patient Information Required:

• Full name and member identification number
• Date of birth and contact details
• Primary and secondary insurance information
• Primary care physician details

Clinical Documentation:

• Current diagnosis with ICD-10 codes
• Relevant medical history and previous treatments
• Supporting clinical notes and laboratory results
• Treatment plan and expected outcomes
• Risk-benefit analysis for the requested medication

Medication-Specific Information:

• Drug name, strength, and dosing schedule
• Duration of treatment requirements
• Alternative medications considered
• Specific therapeutic indications

Step 5: Tracking and Managing Requests

Status Monitoring

The Surescripts portal provides real-time tracking capabilities for all submitted authorization requests. Healthcare providers can monitor progress through various status indicators:

• Submitted: Request received and under initial review
• Pending: Additional clinical information requested
• Approved: Authorization granted for specified duration
• Denied: Request declined with specific reasons provided

Response Management

Surescripts transmits a dynamic electronic question set tailored to the medication from the benefit plan to the EHR. Providers receive targeted questions specific to the requested medication and patient condition, streamlining the review process.

Advanced Features: Touchless Prior Authorization

Revolutionary Automation Technology

Surescripts unveils the first-of-its-kind Touchless Prior Authorization technology, transforming prior authorizations to help alleviate one of healthcare's most pressing challenges for care providers and patients.

How Touchless Prior Authorization Works

Touchless Prior Authorization matches clinical data with determination criteria to help reach a clinically appropriate decision as quickly as possible. It automatically retrieves required information from the patient's electronic health record and sends it to the pharmacy benefit manager (PBM).

Automated Process Flow:

1. Automatic Initiation: The System detects prior authorization requirements during e-prescribing
2. Data Retrieval: Clinical information automatically extracted from EHR
3. Criteria Matching: Patient data compared against approval requirements
4. Instant Decision: When prior authorization requirements are met, the request can be approved without human intervention.

Proven Results and Benefits

In a 2024 pilot, conducted in collaboration with leading health systems such as Fairview Health Services, the appeals and denials caused by a lack of clinical information were reduced by 88% and 68% respectively, and many approvals were completed in less than 30 seconds.

Key Performance Metrics:

• 30-second average approval time with Touchless Prior Authorization
• Significant reduction in manual administrative tasks
• About 40% of prescriptions delayed by the manual prior authorization process are abandoned. Support greater adherence by helping patients get approved medications right away.

Integration with Electronic Health Records

EHR Workflow Integration

Surescripts' prior authorization integrates seamlessly with existing EHR systems, allowing healthcare providers to submit requests without leaving their familiar workflow environment. The system lets users proactively initiate requests and receive quick responses within the EHR.

Benefits of EHR Integration:

• Reduced context switching between systems
• Automatic population of patient data
• Real-time status updates within provider workflow
• Streamlined clinical documentation

Delegate Management

Healthcare providers can add delegates to assist prescribers with prior authorizations. This feature enables practice staff to manage authorization requests on behalf of prescribers, improving workflow efficiency and reducing provider burden.

Common Challenges and Solutions

Addressing Manual Process Inefficiencies

As of 2023, over one-third of medical plans had an entirely manual prior authorization process that depended on phone, mail, fax, and email. Surescripts electronic solutions address these inefficiencies through automated workflows and real-time communication.

Reducing Provider Burnout

Ninety-four percent of physicians say that the prior authorization process delays care, and virtually all (95%) felt that prior authorization somewhat or significantly increases burnout. Electronic prior authorization through Surescripts significantly reduces the administrative burden on healthcare providers.

Improving Patient Outcomes

About 40% of prescriptions delayed by the manual prior authorization process are abandoned. Faster authorization decisions through Surescripts help ensure patients receive necessary medications without delay.

Regulatory Compliance and Future Trends

CMS Interoperability Requirements

CMS finalized the CMS Interoperability and Prior Authorization Final Rule (CMS-0057-F), which sets requirements for Medicare Advantage (MA) organizations, Medicaid, and CHIP programs to improve the electronic exchange of health information and prior authorization processes.

The new regulations mandate:

• Implementation of FHIR-based Prior Authorization APIs by January 1, 2027
• Faster response times with decisions within 72 hours for expedited requests and seven calendar days for standard requests
• Enhanced transparency in the authorization process
• Electronic prior authorization measure reporting for MIPS participants

Industry Transformation

The Interoperability and Prior Authorization Rule has made improved data sharing, higher transparency, and faster decision times compulsory by January 2026. Healthcare organizations must prepare for these regulatory changes by adopting electronic prior authorization systems like Surescripts.

Best Practices for Optimal Results

Documentation Excellence

Comprehensive Clinical Justification:

• Provide detailed medical necessity statements
• Include relevant diagnostic test results
• Document previous treatment attempts and outcomes
• Explain why alternative treatments are inappropriate

Accurate Coding:

• Use current ICD-10 diagnosis codes
• Verify CPT/HCPCS procedure codes
• Ensure coding aligns with clinical documentation

Workflow Optimization

Staff Training:

• Regular training on portal navigation
• Updates on new features and capabilities
• Best practices for documentation
• Emergency procedures for urgent requests

Process Standardization:

• Develop standardized workflows for common requests
• Create templates for frequently submitted authorizations
• Implement quality assurance reviews
• Monitor approval rates and response times

Technology Utilization

EHR Integration:

• Maximize use of integrated authorization features
• Leverage automated data population
• Utilize real-time status updates
• Implement delegate access for efficient workflow management

Conclusion

Surescripts' prior authorization represents the future of medication approval processes, offering healthcare providers powerful tools to streamline workflows, reduce administrative burden, and improve patient outcomes. This technology can meaningfully transform the existing burdensome prior authorization process, helping patients get started on high-quality, affordable, evidence-based treatment that is covered by their health plan -- without delay.

The transition from manual to electronic prior authorization processes provides significant benefits for all stakeholders in the healthcare ecosystem. Healthcare providers gain efficiency and reduce burnout, patients receive faster access to necessary medications, and payers can make more informed decisions with comprehensive clinical data.

Ready to Optimize Your Prior Authorization Process?

If you're looking to streamline your prior authorization workflow, reduce denials, and save valuable staff time, explore automated solutions that integrate seamlessly with your existing systems. Learn how Sprypt's Pre-Authorization platform can transform your practice's approach to prior authorizations with real-time submissions, automated tracking, and intelligent approval predictions.

Frequently Asked Questions

Q: How long does a Surescripts prior authorization take? 

A: Median time from decision request fell by more than two-thirds after implementation—from 18.7 hours to 5.7 hours. With Touchless Prior Authorization, approvals can be completed in 30 seconds or less.

Q: Is there a cost to use the Surescripts Prior Authorization Portal? 

A: The Surescripts Prior Authorization Portal is a free and easy way for prescribers and their staff to submit and manage prior authorization requests for medications online.

Q: Can I submit urgent prior authorization requests through Surescripts? 

A: Yes, the system supports both standard and expedited requests. Under new CMS regulations, expedited requests must receive decisions within 72 hours.

Q: What happens if my prior authorization is denied? 

A: Denied requests include specific reasons for denial, allowing providers to address issues and resubmit with additional clinical information or appeal the decision through appropriate channels.

Q: Do I need special software to access Surescripts prior authorization? 

A: The portal is web-based and accessible through standard browsers. Many EHR systems also offer integrated Surescripts functionality for seamless workflow management.