Veradigm (Allscripts) Bright HealthCare Prior Authorization Automation

Klivira delivers comprehensive Veradigm (Allscripts) Bright HealthCare prior authorization automation, streamlining the complex process of securing approvals for Medicare Advantage beneficiaries.

Revenue cycle leaders and prior authorization coordinators face significant operational hurdles when managing prior authorizations between Veradigm's diverse EMR portfolio and Bright HealthCare's specific requirements. Manual processes lead to delays, increased administrative burden, and potential revenue loss, particularly for high-volume Medicare Advantage services.

The Challenge of Veradigm (Allscripts) Bright HealthCare Prior Authorization

Managing prior authorizations for Bright HealthCare's Medicare Advantage plans from within Veradigm's ecosystem, which includes TouchWorks EHR, Professional EHR, and Sunrise, demands a robust, integrated solution. The variance in data structures and workflow across these Veradigm product lines complicates consistent data extraction and submission, creating bottlenecks for critical patient services.

Navigating Bright HealthCare's Medicare Advantage PA Requirements

Bright HealthCare's focus on Medicare Advantage means prior authorization requirements often involve specific guidelines for specialty medications, advanced imaging, and complex procedures common in this population. Submitting these authorizations typically involves navigating payer portals, utilizing ePA solutions, or submitting via X12 278, each requiring precise data formatting and meticulous follow-up to avoid denials. Klivira streamlines these diverse submission pathways.

Klivira's Seamless Integration with Veradigm EMRs

Klivira integrates directly with Veradigm's ambulatory and small hospital EMRs, leveraging the Veradigm Developer Program and FHIR API. Our solution utilizes FHIR R4 resources like ServiceRequest, MedicationRequest, and DocumentReference, enabling efficient extraction of clinical data. This integration supports SMART App Launch from within the Veradigm clinical UI, providing patient context for a seamless prior authorization workflow.

Key Integration Points within Veradigm Product Lines

**Orders Activity / e-Prescribing:** Capture PA triggers directly from clinician orders for medications, labs, or imaging.
**Patient Chart & Clinical Documentation:** Extract necessary clinical notes, diagnoses (Condition), and observations (Observation) required for payer submission.
**Tasks / Worklists:** Automate task creation and updates for PA status, follow-ups, and payer correspondence, integrating into existing clinician workflows.
**FollowMyHealth Patient Portal:** Support patient notification elements of PA workflows, enhancing patient engagement.
**DocumentReference Write-back:** Deposit submitted PA packets and approval documents directly back into the patient's chart.

Streamlining PA Workflows for Medicare Advantage Services

For Bright HealthCare's Medicare Advantage members, Klivira automates prior authorizations across a spectrum of high-cost, high-volume services. This includes specialty medications (e.g., biologics, GLP-1s), advanced diagnostic imaging (e.g., MRIs, CT scans), and surgical procedures, ensuring that the specific clinical criteria for these services are met and submitted accurately.

Enhancing Operational Efficiency and Compliance Readiness

By automating the Veradigm (Allscripts) Bright HealthCare prior authorization process, organizations can significantly reduce manual effort, accelerate turnaround times, and minimize administrative denials. Klivira's structured approach to data handling and submission also supports considerations for compliance with evolving industry standards, such as those outlined in CMS-0057-F, which mandates electronic prior authorization for Medicare Advantage plans.

Frequently asked questions

How does Klivira handle the different Veradigm EMR products like TouchWorks vs. Sunrise for Bright HealthCare PAs?

Klivira is designed to accommodate the distinct integration surfaces and chart anatomies across Veradigm's product lines, including TouchWorks EHR, Professional EHR, and Sunrise. We configure our integration to match the specific EMR deployment, ensuring accurate data extraction and workflow integration for Bright HealthCare prior authorizations regardless of the underlying Veradigm system.

What specific data does Klivira extract from Veradigm EMRs for Bright HealthCare prior authorizations?

Klivira leverages Veradigm's FHIR R4 APIs to extract PA-relevant clinical and administrative data. This includes patient demographics, encounter details, diagnoses (Condition), ordered services (ServiceRequest), prescribed medications (MedicationRequest), and supporting clinical documentation (DocumentReference), ensuring comprehensive data submission to Bright HealthCare.

How does Klivira submit prior authorizations to Bright HealthCare?

Klivira connects to Bright HealthCare through various industry-standard channels, including direct payer portal automation, ePA networks, and X12 278 transactions. Our platform intelligently routes each prior authorization request through the most efficient and compliant channel, ensuring timely delivery to Bright HealthCare for Medicare Advantage services.

Can Klivira help track the status of Bright HealthCare prior authorizations within Veradigm?

Yes, Klivira integrates with Veradigm's workflow systems, such as Tasks and Worklists, to provide real-time updates on Bright HealthCare prior authorization statuses. This allows PA coordinators to monitor requests directly from their Veradigm EMR, reducing the need to log into multiple payer portals for status checks.

How does Klivira support compliance with electronic prior authorization mandates for Bright HealthCare Medicare Advantage plans?

Klivira's automation platform is built to facilitate electronic prior authorization (ePA) processes, aligning with mandates like CMS-0057-F for Medicare Advantage plans. By standardizing data extraction and submission, Klivira helps organizations meet ePA requirements, contributing to compliance and reducing manual administrative burdens.