Authority approval processing for Pharmaceutical Benefits Scheme (PBS) 012-63020000

Key:

• RMNU to access the PBS main menu
• X (Authorities)

The Authorities processing system opens.

Select one of the following options:

• Record Written Authority (RAUR)
• Record Telephone Authority (RAUR)
• Record After Hours Authority (RAUR)
• Amend an Authority (RAUU)
• Update Patient Comments (RAUC)
• Enquire on an Authority (RAUE)

Identify the patient on the system by:

• Keying the patient's Medicare entitlement, concession or Department of Veterans' Affairs (DVA) number. Confirm the correct patient is found by asking the approved prescriber to state the patient's name, or
• Searching for the patient using first name, surname and date of birth and/or address

The Resources page contains a list of the different search options that can be used to find a patient.

If the patient is located:

• confirm the patient details are correct and select
• patient comments will be shown:
• press [Enter] to proceed
• Previous authorities history for the patient will show:
• Press [PF6] to proceed
• see Table 5, Step 1

If the patient is not located:

• for a written request, contact the clinic to confirm patient's Medicare details. Service Officers can refer the request to Local Peer Support (LPS) if contact is not possible, for example, unable to make outbound calls
• there are certain situations where recording a new patient is appropriate. See Table 4, Step 1

See Table 6, Step 1.

The following groups of information can be keyed:

• Medicare number
• surname, first name and postcode or locality
• surname, first name and postcode search (postcode range, for example 3000-3999 for Victoria)
• surname, first name, postcode range and date of birth

Note: patient name searches will require either a matching address and/or date of birth to confirm match.

Press [Enter].

To search by address:

• press [PF10], or
• key RPQN

Where the approved prescriber has obtained an Authority for the patient previously:

• use the previous Authority prescription number or phone approval number
• press [PF3], then [PF6] (enquiry on an Authority)
• key the prescriber number and dates
• key the surname and prescriber number
• press [Enter]

Verify that the patient is entitled to access the PBS, for example the patient is:

• a newborn infant
• a visitor from a Reciprocal Health Care Agreement (RHCA) country, for example Sweden, who is entitled to access the PBS
• an Australian Defence Force (ADF) member without a Medicare card

See also Reciprocal Health Care Agreements (RHCA) eligibility for Medicare and Pharmaceutical Benefits Scheme (PBS).

Is the Authority Request being processed in:

• Mainframe - go to Step 3
• Online PBS Authorities system - go to Step 4

Search for patient on RAUP screen using name and postcode and enter.

On the RIDB screen.

Key the following patient details:

• full name
• date of birth
• address

Press [PF5].

The Record Authority Details (RAUB) screen will show.

Note: if the Authority request is for an unnamed newborn, Service Officers must key 'Newborn' as the child's first name when entering the patient's details. If there are multiple children, key 'Newborn 1', 'Newborn 2' and so on.

See also Processing Written Authority requests.

On the Patient search screen:

• Key the special Medicare number 25437766611 in the Medicare number field
• Press [Enter] or select Search
• The bottom of the screen will show the following fields to be keyed:
• First Name
• Last Name
• Date of birth
• Gender

Select Next to continue with the Authority application.

Note: if the Authority request is for an unnamed newborn, Service Officers must key 'Newborn' as the child's first name when entering the patient's details. If there are multiple children, key 'Newborn 1', 'Newborn 2' and so on.

For phone approvals, confirm the patient's details with the approved prescriber.

If the approved prescriber cannot confirm the patient's details (including written approvals):

• do not approve the patient (the approved prescriber can issue a private prescription)
• refer the patient to a Medicare Service Centre to get a temporary Medicare number

See Table 6, Step 1.

Is the patient a visitor from a RHCA country?

• Yes, in the Authority Comments field, enter the RHCA country that the patient is visiting from
• No, procedure ends here

See Reciprocal Health Care Agreements (RHCA) eligibility for Medicare and Pharmaceutical Benefits Scheme (PBS) for more details.

Press [PF10] to show a summary of previous Authority details.

Note: to view details of a single record, select the corresponding number and press [Enter].

Check if previous supplies exist for the same item.

If:

• previous supplies exist and the system shows more than:
• 2 months' supply, or
• one month's supply in the case of Dangerous Drugs
• go to Step 3
• there is no outstanding supply:
• proceed with the Authority approval
• see Table 6, Step 1

See Too soon rule.

Is the application acceptable for an early approval?

• Yes:
• press [PF3] and record the reason for early approval
• proceed with the final assessment, see Table 11, Step 1
• No:
• press [PF3] and record the reason for rejection in Authority Comments field. See Record comments for Authority approval application

Note: refer any situations that do not meet the Too soon rule to the Pharmaceutical Adviser (PA).

Key the Authority prescription number in the Authority ID field.

Authority applications keyed with an incorrect authority number will cause a delay for the customer at the pharmacy, and result in an increased number of calls to the PBS general enquiry line.

After keying the number, press [Enter] to confirm.

If the message 'Authority number may be invalid' appears and the number keyed is highlighted in red:

• Delete the number and press [Enter]. The message 'Authority ID must be entered' will appear.
  Note: if this is not done and the Authority number is re-keyed, it will appear as though the Authority number is correct (will appear green with no error message) even if it is incorrect
• Ask the approved prescriber to repeat the Authority prescription number and re-key the number. If the:
• Authority prescription number is now correct, press [Enter] to confirm, go to Step 3
• Invalid Authority prescription number warning persists, acknowledge the warning by pressing [Enter], and add the following Authority comment 'Confirmed Auth ID'
  Note: if this Authority comment is not entered, it will be considered an error and feedback will be provided. Go to Step 3

See Table 7, Step 1.

To locate the approved prescriber:

• key the prescriber number, and press [Enter], or
• search for the approved prescriber using the below combination of letters:
• state or territory code, see the Resources page for the state and territory code list
• first 4 letters of the approved prescriber's surname
• first letter of the approved prescriber's first name

Example: SBROWJ for Doctor John Brown from South Australia.

Note: if the approved prescriber does not have a prescriber number, refer to the Provider Liaisons area within the caller's state.

Confirm and select the approved prescriber.

Confirm the application is being made by an approved prescriber. For:

• phone applications, ask caller for full name or state the caller's full name, for example, 'Thank you Dr Smith…'
• written applications, see Processing Written Authority requests

See Table 8, Step 1.

In the Item Code field, key one of the following:

• item code for the medication
• extemporaneous item code, for example, creams, paste and lotions
• first 4-6 characters of the drug to search for the medication (for example, CITALO for Citalopram)

Press [Enter].

• An individual item or a multiple selection will show
• If an item does not show, advise the approved prescriber the medication is not a PBS benefit item. Enter details provided, reject and record

Select:

• requested strength
• requested form

Where applicable, key or select:

• quantity and repeats
• Highly Specialised Drugs (HSD)
• Therapeutic Price Exemption (TPX)
• Special Patient Contribution Exemption (SPX)
• Public Hospital (PUB)

Press [Enter].

See Table 9, Step 1.

Assess the benefit item. If an:

• Authority required or Restricted benefit item with increase in quantity and/or repeats, go to Step 2
• Unrestricted benefit item:
• select the statement 'Increased quantity and/or repeats are required as those listed in the Schedule are insufficient for patient treatment within PBS guidelines' with / (forward slash) and press [Enter]
• see Table 10, Step 1

See Handle request for increased quantity and/or repeats for unrestricted, restricted and Authority benefit.

Select criteria and assess the restriction. For phone applications, ask for the criteria. If the restriction criteria has:

• been met, press [Enter]
• not been met
• tell the approved prescriber
• key an assessment result of 3 (rejected)
• key a reason code for the rejection
• press [PF8] to update the rejected entry

See Handle request for increased quantity and/or repeats for unrestricted, restricted and Authority benefit.

If questions show:

• Read the questions to the approved prescriber (for phone approvals), unless the prescriber provides the required information for the Q&As for an authority approval
• Go to display. See Table 10, Step 1
• Assess answers against the restriction criteria and record responses

Assess restrictions to make sure compliance with guidelines, and record responses.

If a prescriber goes out of their software system at any time to get more information needed to complete the application, the authority ID number may change. Staff must confirm the authority ID number before generating the approval number.

Key:

• dosage
• quantity and repeats

Assess the request to make sure compliance with quantity and repeat guidelines, see Handle request for increased quantity and/or repeats for unrestricted, restricted and Authority benefit. If the quantity and repeat guidelines are:

• Met, go to Table 11, Step 1
• Not met, for:
• authority required (telephone) items, tell approved prescriber of the allowable quantity and repeats. See information about Calculation of allowable quantity and repeats and How to request changes to quantity and repeats for authority required (telephone approvals – authority required (written) items
• written applications, see information about reducing quantity and repeats

Then go to Table 11, Step 1.

Key the necessary information on the Record Authority Details (RAUB) screen, and press [Enter].

Press [PF10] to check the patient history for any outstanding supply. See Table 5, Step 1.

Enter any Authority comments in the Authority Comments field.

See Record comments for Authority approval application.

• press [PF12] to view any patient comments
• make final assessment decision
• read the information back to the prescriber including medication, form, strength, quantity and repeats
• add the assessment result, and press [PF8]

See Codes in the Mainframe for Pharmaceutical Benefits Scheme (PBS).

If the application is:

• Approved, the system will show a phone approval number. Inform the prescriber of the phone approval number. The prescriber must note the phone approval number on the Authority prescription form
• Rejected, record the application

Note: all phone authorities must be recorded regardless of outcome. Unapproved authorities must be recorded and rejected with the assessment result 3 (rejected).

If the application is:

• Approved - complete an approval assessment letter:
• With prescriber details
• With patient name
• With authority prescription number and medication name
• With PBS Authority approval number and item code
• Use window envelopes where available
• Send to approved prescriber
• Rejected:
• Complete the rejection assessment letter, and
• Send to approved prescriber

or

For applications received through HPOS:

• find the Health Professional Online Services (HPOS) mail, using the reference number provided in Workload Manager (WLM)
• send the result of the written Authority application by replying to the email

See Processing Written Authority requests.

Further approvals for:

• same patient, press [PF6]
• new patient, press [PF11]

Add any patient comments, as required.

See Record comments for Authority approval application.

Access the Authority system. See Table 1, Step 1.

Record and assess the application for approval to supply HSDs as for a standard Authority approval application.

• Identify patient. See Table 2, Step 1
• Key Authority prescription number. See Table 6, Step 1.
• Identify approved prescriber. See Table 7, Step 1
• Identify medication. See Table 8, Step 1
• Select and access restrictions and Quality Assurances (QA). See Table 9, Step 1
• Assess quantity and repeats. See Table 10, Step 1

On the Record Authority Details (RAUB) screen, key:

• hospital provider number
• number of days treatment (quantity divided by dose = number of days treatment)

Finalise the application, see Table 11, Step 1.

Select the item code with 'TPX' shown.

Ask the approved prescriber to state the reason for exemption.

Approvals are generated by the system with a prefix of TPX added to the existing approval number format, for example TPX M1346 RX.

Endorse this approval number, including the prefix, on written authority approvals.

See Pricing and fees in Pharmaceutical Benefits Scheme (PBS).

Determine if the:

• approved prescriber is requesting a SPX
• request is a Reg 13 supply

Select the item code with 'SPX' shown.

Ask the approved prescriber to state the patient's medical condition and reason for exemption.

Note: for written applications, the Service Officer must confirm the application meets the restriction criteria.

Approvals are generated by the system with a prefix of SPX added to the existing approval number format, for example SPX M1346 RX.

Endorse this approval number, including the prefix, on written authority approvals.

See Pricing and fees in Pharmaceutical Benefits Scheme (PBS).

Process as usual for written or phone approvals.

Determine the preparation type from the Schedule, either:

• Standard Formula preparations (as identified by a Reference, for example, APF, QHF, BPC, BP - Note: item codes begin with a '7')
• Non-standard preparations for example, cream 13Q, lotion 39C, solution 52R

Key:

• quantity for approval in the units of the maximum quantity allowed for that preparation (for example, for 13Q - cream - key quantity as grams)
• number of repeats
• daily dosage - specified by the approved prescriber
• restriction code 9999 (for increased quantity and/or repeats)
• add Authority comments:
• For non-standards preparations, ingredients and percentile amounts requested - including strength (% or by volume or weight, for example, mL or g)
• explanation in dosage field and rate of usage, for example, 'apply BD, 500G per month'

Note: it is important that the restriction code is selected before entering any Authority comments. If the Authority comments are entered first, they will be deleted when the restriction code is selected and the Service Officer will be required to re-enter ingredients again.