Streamlining Veradigm (Allscripts) BCBS Texas Prior Authorization Automation

The Veradigm (Allscripts) EMR Ecosystem and Prior Authorization

The Veradigm portfolio, encompassing TouchWorks EHR, Professional EHR, and Sunrise, offers robust clinical documentation but presents varied integration surfaces for prior authorization. Klivira leverages the unified Veradigm Developer Program and FHIR R4 APIs to connect across these product lines, extracting critical patient and clinical data needed for BCBS Texas submissions.

BCBS Texas Prior Authorization Submission Pathways

BCBS Texas, an HCSC-owned plan, primarily processes medical benefit precertifications through the BCBSTX provider portal and Availity Essentials, alongside X12 278 transactions via clearinghouses. Pharmacy benefit prior authorizations for BCBS Texas members route through Prime Therapeutics, often utilizing CoverMyMeds and Surescripts ePA. Klivira's platform is engineered to connect to these diverse channels, streamlining submissions.

Seamless Klivira Integration with Veradigm (Allscripts)

Klivira integrates with Veradigm (Allscripts) EMRs via SMART App Launch from within the clinical UI, providing patient context directly to the automation platform. We utilize FHIR R4 APIs to securely retrieve essential US Core resources, including Patient, Encounter, Coverage, and ServiceRequest data. This deep integration minimizes manual data entry and ensures that prior authorization requests are built on accurate, up-to-date clinical information.

Automated BCBS Texas Policy Adherence and Submission

Klivira's automation engine incorporates BCBS Texas medical policies and clinical utilization management guidelines, accessible via their provider site through Availity. Our system intelligently identifies the correct submission channel and required documentation based on the specific service or medication. This ensures that prior authorization requests are complete and aligned with BCBS Texas criteria before submission, reducing common denial reasons like insufficient documentation or medical necessity.

Optimizing Specific Workflows for Veradigm (Allscripts) and BCBS Texas

• Medical Benefit Prior Authorizations: Automating submissions for procedures and services requiring precertification.
• Pharmacy Benefit ePA: Streamlining electronic prior authorizations for medications managed by Prime Therapeutics.
• Specialty Drug PAs: Managing complex prior authorization requirements for specialty medications on both medical and pharmacy benefits.
• Advanced Imaging and Cardiology PAs: Facilitating submissions for high-cost diagnostic services often routed through specialty benefit management.
• Behavioral Health PAs: Supporting prior authorization processes for mental health and substance use services.
• Texas Medicaid (STAR/STAR Kids) PAs: Adhering to specific Texas Health and Human Services rules for managed care plans.

Ensuring Compliance and Timely Decisions

Klivira helps clinics and hospitals using Veradigm EMRs meet critical BCBS Texas prior authorization timelines. For commercial lines, our processes align with Texas Department of Insurance regulations. For Medicare Advantage, Medicaid managed care (STAR/STAR Kids), and CHIP, Klivira supports compliance with CMS-0057-F mandates, including the 72-hour standard and 24-hour expedited decision timeframes. We facilitate the routing of denial reasons and support the appeal pathway outlined in the BCBS Texas provider manual.