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Electronic prior authorization (ePA)

Komodo Care Connect supports integrations with external vendors to facilitate the electronic submission and processing of prior authorizations. With electronic prior authorization (ePA), users can submit prior authorization requests from Komodo Care Connect as well as receive updates and results within Komodo Care Connect via a designated ePA provider for a care program.

Note

The ePA functionality currently only supports a single ePA vendor for each care program.

To set up and configure the ePA functionality for a care program, follow the steps below. Some steps may reference a sample care program and drug called Kalytex (KTX) as an example.

  1. Implement a custom handler class for the ePA Vendor API Interface (PJN_EpaVendorApiIntf). This will build out the prior authorization to be sent to the designated ePA vendor and create a new Prior Authorization (mvn__PJN_Prior_Authorization__c) record on the parent Member Plan (mvn__PJN_Member_Plan__c) record.

    1. Use the ePA Request (PJN_EpaRequest) class to build the JSON object containing the required and relevant data to be sent to the designated ePA vendor and return a Prior Authorization record with the serialized JSON string.

    2. Use the ePA Response (PJN_EpaResponse) class to build a Prior Authorization record with the appropriate Komodo Care Connect values.

  2. Create an Interface Handler (mvn__Interface_Handler__mdt) metadata record. This will be used by the ePA Request class via the ePA Vendor API Interface handler class to generate the prior authorization request for the ePA vendor.

    Table 125. Sample ePA mvn__Interface_Handler__mdt record

    Field label

    Sample value

    Label

    Electronic Prior Auth - Kalytex

    Interface Handler Name

    MVN_KTX_ePA

    Context

    Electronic Prior Authorization

    Interface

    mvn.PJN_EpaVendorApiIntf

    Class Namespace

    N/A

    Class

    The name of the ePA Vendor API Interface handler class created in step 1.

    Sequence

    1

    Criteria

    {
    "path" : "mvn__PJN_Care_Plan__r.mvn__PJN_Program_DeveloperName__c",
    "operator" : "Equals",
    "value" : "MVN_KTX"
}

    Active?

    ✓



  3. Create an ePA Field Mapping (mvn__PJN_Epa_Field_Mapping__mdt) metadata record for each piece of data to be sent to the ePA vendor in the prior authorization request.

    Table 126. Sample ePA mvn__PJN_Epa_Field_Mapping__mdt record

    Field label

    Sample value

    Label

    KTX - Patient First Name

    ePA Field Mapping Name

    MVN_KTX_Patient_First_Name

    ePA Interface Handler

    The Interface Handler metadata record created in step 2 (e.g., Electronic Prior Auth - Kalytex).

    ePA Field API Path

    mvn__PJN_Patient__r

    Vendor JSON Key

    patient.firstname

    Is Required?

    ✓



  4. Add the Submit ePA (PJN_Submit_ePA) quick action, which references the pjnEpaSubmitModal Lightning Web Component (LWC), to a Member Plan page layout. The LWC will look for an interface handler whose criteria the Member Plan record meets.