Optimizing Veradigm (Allscripts) Blue Shield of California Prior Authorization Automation

Klivira delivers seamless Veradigm (Allscripts) Blue Shield of California prior authorization automation, transforming a complex administrative burden into an efficient, integrated workflow.

Revenue cycle leaders and prior authorization coordinators frequently navigate the intricacies of payer-specific requirements from within their EMRs. For organizations utilizing Veradigm's diverse portfolio—including TouchWorks EHR, Professional EHR, and Sunrise—submitting prior authorizations to Blue Shield of California presents unique challenges in channel selection, policy interpretation, and status tracking.

Navigating Blue Shield of California PA from Veradigm EMRs

Submitting prior authorizations to Blue Shield of California from within a Veradigm EMR, such as TouchWorks EHR or Professional EHR, often involves navigating multiple channels. While the Blue Shield Provider Connection portal (accessible via Availity) serves as a primary hub for medical benefit PA, many organizations also leverage X12 278 transactions through clearinghouses. Klivira streamlines this process, ensuring submissions align with BSCA's requirements and California-specific regulations.

Klivira's Integration with Veradigm's EMR Portfolio

Klivira integrates directly with Veradigm's modern EMR product lines, including TouchWorks EHR and Professional EHR, primarily via their FHIR API and SMART App Launch capabilities. This leverages the Veradigm Developer Program, allowing Klivira to launch from within the clinical UI with patient context. For deployments utilizing legacy interfaces, Klivira can also integrate via the Veradigm Unity API or HL7 v2, ensuring comprehensive connectivity across Veradigm's diverse ambulatory and inpatient (Sunrise) footprints.

Key Advantages for Veradigm (Allscripts) Users

Automated submission to Blue Shield of California's Availity-powered Provider Connection portal and X12 278 channels.
Real-time access to Blue Shield of California medical policies and clinical UM guidelines, including those based on MCG or NCCN.
Adherence to California-specific PA turnaround requirements from DMHC and CDI, and federal CMS-0057-F mandates for applicable plans.
Seamless integration with Veradigm's chart anatomy (e.g., Patient Chart, Orders activity) for efficient documentation and status updates.
Support for diverse Veradigm product lines, accounting for variations between TouchWorks EHR, Professional EHR, and Sunrise.

Navigating Specialty-Specific Prior Authorizations

Blue Shield of California manages prior authorizations for various specialty services, including advanced imaging, cardiology, and medical-benefit specialty drugs. Klivira streamlines these complex workflows by understanding BSCA's routing to specialty benefit-management vendors where applicable, and by ensuring that necessary clinical documentation from Veradigm EMRs supports the specific criteria for these high-cost services.

Ensuring Compliance with California PA Regulations

California's prior authorization landscape is uniquely shaped by regulations from the California Department of Managed Health Care (DMHC) for HMO plans and the California Department of Insurance (CDI) for PPO plans. Klivira helps organizations manage these distinct requirements, including considerations for behavioral health parity under California SB 855 and the phased timeframes introduced by CMS-0057-F for Blue Shield of California's Medicare Advantage and Covered California plans.

Frequently asked questions

How does Klivira integrate with different Veradigm EMR products like TouchWorks EHR and Sunrise?

Klivira primarily leverages Veradigm's modern FHIR API and SMART App Launch via the Veradigm Developer Program for ambulatory products like TouchWorks EHR and Professional EHR. For Sunrise or specific customer configurations, we also support integration via the Veradigm Unity API or HL7 v2 interfaces, adapting to the distinct technical surfaces of each product line.

Which Blue Shield of California prior authorization submission channels does Klivira support?

Klivira automates submissions to Blue Shield of California through its primary provider portal (Blue Shield Provider Connection, often accessed via Availity) and via X12 278 electronic transactions through clearinghouses. This ensures comprehensive coverage for medical benefit prior authorizations.

Can Klivira help our organization comply with California-specific PA regulations for Blue Shield of California?

Yes, Klivira is designed to incorporate California's unique regulatory environment, including turnaround time mandates from the DMHC and CDI, as well as behavioral health parity considerations under California SB 855. We facilitate the submission of compliant documentation to meet these state-specific requirements.

How does Klivira handle prior authorizations for specialty drugs covered by Blue Shield of California?

For medical-benefit specialty drugs, Klivira routes requests through Blue Shield of California's medical PA channels. For pharmacy-benefit specialty drugs, the process aligns with BSCA's configured specialty pharmacy operations. Klivira ensures the necessary clinical documentation from your Veradigm EMR supports these specific drug criteria.

Does Klivira automate prior authorizations for Blue Shield of California's Medicare Advantage plans?

Yes, Klivira supports prior authorization automation for Blue Shield of California's Medicare Advantage plans. This includes adherence to the phased implementation timeframes and requirements outlined in CMS-0057-F, ensuring your submissions meet federal mandates for these beneficiaries.