Optimizing AdvancedMD Xarelto Prior Authorization Workflows

Xarelto PA Flow within AdvancedMD Order Entry

When Xarelto is ordered within AdvancedMD's EHR, the system's ambulatory focus often means a streamlined but still PA-reliant process. Klivira intercepts these orders at the point of prescribing, identifying Xarelto as a medication requiring prior authorization. This proactive identification within the AdvancedMD workflow ensures that PA initiation occurs early, preventing delays in patient care.

AdvancedMD's Pharmacy vs. Medical Benefit Split for DOACs

For direct oral anticoagulants (DOACs) like Xarelto, AdvancedMD users navigate both pharmacy and medical benefit considerations. Klivira intelligently determines the appropriate pathway, leveraging the AdvancedMD API to discern if the PA requires an NCPDP SCRIPT ePA transaction for pharmacy benefits or an X12 278 submission for medical benefits, ensuring the correct data elements are prepared for payer submission.

Documentation Patterns Klivira Pulls from AdvancedMD for Xarelto PA

• Diagnosis codes (e.g., I48.x for atrial fibrillation, I82.x for VTE) from the AdvancedMD problem list.
• Relevant clinical notes detailing patient history, contraindications to alternative therapies, and previous treatment failures.
• Lab results such as creatinine clearance (CrCl) or liver function tests, crucial for Xarelto dosing and medical necessity.
• Medication history to support step therapy requirements or formulary exceptions.
• Provider attestations and clinical rationale documented directly within AdvancedMD encounters.

Seamless ePA Integration and Specialty Pharmacy Routing

Klivira integrates directly with AdvancedMD via its API to facilitate electronic prior authorization (ePA) submissions for Xarelto. Beyond PA, our platform also assists in routing prescriptions to the appropriate specialty pharmacies, a common requirement for DOACs. This reduces manual faxing and phone calls, ensuring a smoother transition from prescription to fulfillment.

Addressing Step Therapy and Formulary Challenges for Xarelto

Many payers impose step therapy protocols or specific formulary requirements for Xarelto. Klivira's system is configured to identify these payer-specific rules by analyzing the patient's insurance plan and the ordered medication within AdvancedMD. We then prompt for or automatically extract the necessary documentation to justify Xarelto, such as previous failed trials of warfarin or other anticoagulants, directly from the AdvancedMD EHR.