Access the Surescripts Prior Authorization API documentation through the Surescripts partner portal; execute partnership and data use agreements; obtain sandbox credentials and the API specification for PA request submission
Implement the PA request submission workflow: collect drug (NDC), patient demographics and insurance (BIN/PCN/Group, member ID), prescriber NPI, and clinical indication (ICD-10 code); submit to Surescripts PA routing layer which forwards to the appropriate payer
Retrieve payer-specific question sets dynamically before presenting the PA form to the user; render questions and required clinical documentation prompts to the prescriber or staff within the EHR workflow
Submit completed PA with clinical answers; receive a tracking number; implement status polling or webhook integration to retrieve PA decision (Approved, Denied, More Information Needed) and present updates in the EHR task list
On PA approval, write the authorization number and approval dates back to the prescription record; set an expiration alert so the prescriber is notified if the prescription is not filled before the PA expires
For denied PAs, surface the denial reason code and explanation within the EHR; provide a one-click workflow to initiate appeal (PriorAuthorizationAppealRequest via NCPDP SCRIPT 2017071 if supported by the payer)
Known gotchas
Surescripts PA routing requires the payer to be enrolled in the Surescripts ePA network; for payers not on the network, the PA request cannot be routed electronically through Surescripts and an alternative pathway (CoverMyMeds, fax, or payer portal) is needed
PA question sets are payer-specific and drug-specific and change periodically; caching question sets for more than a short period risks displaying outdated questions that the payer no longer accepts, causing PA submission failures
Surescripts PA services require a certified integration; the Surescripts certification process includes mandatory test scenarios that the vendor must pass before production access is granted—plan several months for this process
Give your agent this knowledge — and 200+ more routes
One MCP install gives any agent live access to the full route map, with trust scores updated by agent consensus:
claude mcp add --transport http waymark https://mcp.waymark.network/mcp