Initiate a specialty pharmacy prior authorization workflow via CoverMyMeds API when a pharmacy claim returns a PA-required rejection

Steps

1. Detect the PA-required rejection: parse the NCPDP D.0 B1 response for reject code 75 (Prior Authorization Required) or reject code 76 (Plan Limitations Exceeded requiring PA)
2. Call the CoverMyMeds REST API POST /requests endpoint with the drug NDC, patient demographics (name, DOB, gender, member ID), prescriber NPI, and pharmacy NPI; include the payer BIN/PCN/Group to ensure the PA request is routed to the correct plan
3. Retrieve the returned PA request token and request_id; present the PA request URL or deep link to the prescriber or pharmacy staff so they can provide clinical documentation in the CoverMyMeds web portal or API
4. Poll GET /requests/{request_id} for status updates (Pending, Approved, Denied, MoreInfoNeeded) or configure webhook callbacks if CoverMyMeds API supports them for your integration tier
5. On Approved status, extract the authorization number from the response and populate it in the pharmacy management system's PA Number field; resubmit the B1 claim with the PA number in Field ID 461
6. On Denied status, surface the denial reason to the prescriber and initiate appeal or therapeutic alternative prescribing workflow