Veradigm (Allscripts) CareSource Prior Authorization Automation

The Challenge of Prior Authorization for Veradigm Users with CareSource

Healthcare organizations relying on Veradigm's portfolio, including TouchWorks EHR, Professional EHR, and Sunrise, often face manual and fragmented processes when securing prior authorizations from CareSource. This includes navigating various payer portals, faxing documentation, and manually tracking statuses, leading to staff burden, delayed care, and potential revenue loss. CareSource's focus on Medicaid and ACA plans means specific formulary rules and medical necessity criteria that require precise documentation and timely submission.

Klivira's Deep Integration with Veradigm (Allscripts) EMRs

Klivira integrates directly with Veradigm's modern EMR product lines through the Veradigm Developer Program, leveraging FHIR R4 APIs and SMART App Launch capabilities. This allows for the seamless extraction of critical patient and clinical data—such as Patient, Encounter, Coverage, ServiceRequest, MedicationRequest, and DocumentReference resources—directly from your TouchWorks EHR, Professional EHR, or Sunrise system. Our platform is designed to adapt to the technical nuances across Veradigm's ambulatory and inpatient offerings, ensuring consistent data flow for prior authorization workflows.

Key Veradigm Integration Points for Prior Authorization

• **FHIR R4 API Connectivity:** Securely access US Core data elements for automated PA submission.
• **SMART App Launch:** Embed Klivira directly within the Veradigm clinical UI for context-aware workflows.
• **Orders Activity & e-Prescribing:** Capture PA triggers directly from clinician orders and medication requests.
• **Clinical Documentation & Notes:** Extract and attach necessary supporting documentation automatically.
• **Tasks & Worklists:** Route PA status updates and follow-up actions to relevant staff worklists.
• **Limited Write-Back:** Support for updating PA status (e.g., via DocumentReference or Task resources) back into the EMR.

Streamlining CareSource Prior Authorizations from Veradigm

Klivira automates the submission of prior authorizations to CareSource by intelligently routing requests through the most efficient channels. This includes leveraging common ePA partners, direct portal integrations where available, and X12 278 transactions. Our platform ensures that all necessary clinical documentation, pulled directly from your Veradigm EMR, is accurately formatted and submitted according to CareSource's specific requirements, minimizing manual intervention and reducing the likelihood of denials.

Optimizing Workflows for CareSource's Medicaid and ACA Populations

Given CareSource's significant presence in Medicaid and ACA markets, Klivira focuses on optimizing PA workflows for common services and medications relevant to these populations. This includes efficient processing for specialty drugs, imaging services, and surgical procedures that frequently require prior authorization. By integrating with Veradigm's orders and e-prescribing modules, we ensure that PA requests are initiated proactively, aligning with CareSource's policy libraries and medical necessity guidelines, which helps prevent retrospective denials.

Enhancing Operational Efficiency and Compliance

Implementing Klivira for Veradigm-CareSource prior authorization automation not only reduces administrative burden but also provides a comprehensive audit trail for every PA request. Our platform helps ensure that your processes align with HIPAA and PHI best practices, offering transparent tracking of all submissions and communications. This empowers your revenue cycle and prior authorization teams to focus on patient care rather than administrative overhead, while maintaining compliance considerations to discuss with your compliance team.