Streamlining Veradigm (Allscripts) BCBS Illinois Prior Authorization Automation

Klivira automates prior authorization workflows for organizations using Veradigm (Allscripts) EMRs to submit to BCBS Illinois, significantly reducing administrative burden and accelerating care delivery.

Revenue cycle and prior authorization teams face unique challenges managing authorizations for BCBS Illinois members from within the diverse Veradigm EMR ecosystem. Manual submissions via payer portals like Availity or the BCBSIL provider portal, coupled with varying EMR workflows across TouchWorks, Professional EHR, and Sunrise, often lead to delays and increased denial rates. Klivira provides a purpose-built solution to connect these critical systems.

Navigating BCBS Illinois Prior Authorization Channels from Veradigm EMRs

BCBS Illinois, an HCSC-owned plan, requires prior authorizations across various service lines, routing medical PAs through Availity Essentials and their dedicated provider portal. Pharmacy prior authorizations for BCBSIL members are typically managed through Prime Therapeutics, an HCSC-affiliated PBM. Klivira centralizes these disparate submission channels, enabling a unified workflow directly from your Veradigm EMR.

Klivira's Deep Integration with the Veradigm Ecosystem

Our platform integrates directly with Veradigm EMRs—including TouchWorks EHR, Professional EHR, and Sunrise—leveraging the Veradigm Developer Program and modern FHIR R4 APIs. This allows for seamless extraction of patient, encounter, coverage, and service request data (US Core resources) directly from the EMR, minimizing manual data entry and ensuring data accuracy for BCBS Illinois submissions. Klivira also supports SMART App Launch for in-workflow access from the clinical UI, providing patient context to streamline PA initiation.

Streamlining Prior Authorization Workflows for Key Service Lines

The complexity of prior authorizations for BCBS Illinois spans a wide range of services, including advanced imaging, specialty medications (such as biologics), and various surgical procedures. Klivira automates the assembly of comprehensive PA packets by extracting relevant clinical documentation from the Veradigm patient chart, orders activity, and clinical notes, ensuring that all necessary information for BCBSIL's utilization management policies is included.

Key Integration Points for Automated PA Submission

FHIR API-driven data extraction for Patient, Encounter, Coverage, and ServiceRequest resources from Veradigm EMRs.
SMART App Launch for contextual application access directly within the Veradigm clinical workflow.
Programmatic submission to BCBS Illinois via X12 278, Availity, and ePA partners like Prime Therapeutics.
Automated write-back of prior authorization status, approval documents (via DocumentReference), and workflow tasks into the Veradigm EMR chart.
Integration with Veradigm's tasking and worklist systems for PA follow-up and appeals management.

Ensuring Data Integrity and Workflow Continuity

By leveraging secure, standards-based integrations, Klivira ensures that ePHI is handled in compliance with HIPAA requirements during data exchange between your Veradigm EMR and BCBS Illinois. Our solution reduces the risk of errors associated with manual data entry and portal hopping, providing a consistent, auditable trail of all prior authorization activities within your existing EMR workflows, including updates to clinical documentation and task lists.

Frequently asked questions

How does Klivira handle different Veradigm product lines (TouchWorks, Sunrise, Practice Fusion) when integrating with BCBS Illinois?

Klivira is designed to accommodate the distinct integration surfaces and chart anatomies of Veradigm's diverse product lines. We leverage the Veradigm Developer Program and FHIR APIs for modern systems like TouchWorks EHR and Professional EHR, while also understanding the nuances of Sunrise and Practice Fusion, ensuring a tailored and effective integration for BCBS Illinois prior authorizations.

What BCBS Illinois submission channels does Klivira support for prior authorizations?

Klivira supports all primary BCBS Illinois prior authorization submission channels. This includes electronic submissions via X12 278, direct integration with Availity Essentials, and connectivity to the BCBSIL provider portal. For pharmacy benefit PAs, we integrate with Prime Therapeutics, streamlining the entire authorization process.

Can Klivira automate prior authorizations for specialty medications managed by Prime Therapeutics for BCBS Illinois members?

Yes, Klivira automates pharmacy prior authorizations for specialty medications for BCBS Illinois members by integrating with Prime Therapeutics, the HCSC-affiliated PBM. Our platform extracts necessary prescription and clinical data from your Veradigm EMR to facilitate efficient ePA submission and status tracking.

How does Klivira integrate prior authorization status updates back into our Veradigm EMR?

Klivira provides robust write-back capabilities, ensuring that prior authorization status updates, approval letters, and denial notifications are automatically documented within your Veradigm EMR. This is typically achieved by creating DocumentReference entries for PA packets and utilizing Task resources to update clinical worklists, maintaining a comprehensive record directly in the patient's chart.

Does Klivira leverage FHIR APIs for data exchange with Veradigm EMRs?

Yes, Klivira primarily leverages FHIR R4 APIs, including US Core resources, for secure and standardized data exchange with modern Veradigm EMRs. This allows us to extract critical patient, coverage, and service request information efficiently, supporting accurate and timely prior authorization submissions to BCBS Illinois.

What types of prior authorizations can Klivira automate for BCBS Illinois plans?

Klivira can automate a broad spectrum of prior authorizations for BCBS Illinois plans, covering both medical and pharmacy benefits. This includes, but is not limited to, advanced imaging services, surgical procedures, specialty medications (e.g., biologics), durable medical equipment, and other high-cost or high-utilization services requiring pre-service approval.