Achieving Veradigm (Allscripts) Highmark Prior Authorization Automation

Klivira delivers comprehensive Veradigm (Allscripts) Highmark prior authorization automation, streamlining the complex process of securing approvals for Highmark members directly from your Veradigm EMR.

Revenue cycle directors and prior authorization coordinators face significant operational overhead managing prior authorizations between diverse EMR systems and payer requirements. For organizations utilizing Veradigm's portfolio—including TouchWorks, Professional EHR, or Sunrise—and serving Highmark members across Pennsylvania, West Virginia, Delaware, and New York, optimizing this workflow is critical for efficiency and patient care.

The Veradigm-Highmark Prior Authorization Challenge

Manual PA submissions from Veradigm EMRs to Highmark's various channels introduce delays and administrative burden. Navigating distinct workflows for medical benefits via Availity or X12 278, and the need to extract comprehensive clinical documentation from Veradigm's diverse product lines, consumes valuable staff time and impacts turnaround times.

Klivira's Integration Architecture with Veradigm (Allscripts)

Klivira integrates directly with Veradigm's EMR platforms—TouchWorks EHR, Professional EHR, and Sunrise—leveraging the Veradigm Developer Program and FHIR R4 APIs. This enables secure, patient-contextual data exchange, extracting necessary clinical data (Patient, Encounter, Coverage, ServiceRequest, MedicationRequest, DocumentReference, Practitioner, Condition, Observation) for PA requests. We also support SMART App Launch for seamless access from within the clinical UI.

Streamlining Highmark Prior Authorization Submissions

Klivira automates the submission process to Highmark across its various channels. For medical benefit prior authorizations, we facilitate submissions through Availity Essentials and via X12 278 transactions to supported clearinghouses. Our platform is designed to adapt to Highmark's utilization management policies and state-mandated turnaround times across PA, WV, DE, and NY, ensuring compliance and efficiency.

Enhanced PA Workflows for Veradigm and Highmark

Automated data extraction from Veradigm's Patient Chart, Clinical Documentation, and Orders activity.
Direct submission of medical benefit prior authorizations to Highmark via Availity or X12 278.
Proactive identification of orders in Veradigm's e-Prescribing and Orders modules requiring Highmark PA.
Write-back capabilities for PA status updates and payer correspondence into Veradigm's Tasks/Worklists and Clinical Documentation.
Support for specialty benefit management vendor routing where Highmark utilizes these for advanced imaging or specific procedures.

Compliance and Operational Efficiency with Klivira

Klivira's platform helps organizations meet the operational demands of prior authorization, including considerations for CMS-0057-F for Highmark's Medicare Advantage and Medicaid managed care plans. By reducing manual data entry and tracking, we enhance data accuracy and free PA coordinators to focus on clinical review and patient advocacy, rather than administrative tasks.

Navigating Veradigm Product Line Nuances for Highmark PA

The Veradigm portfolio encompasses distinct product lines like TouchWorks, Professional EHR, Sunrise, and Practice Fusion, each with specific integration surfaces and chart anatomies. Klivira's solution is engineered to account for these variances, ensuring consistent and reliable prior authorization workflows for Highmark members, regardless of the specific Veradigm EMR in use.

Frequently asked questions

How does Klivira integrate with my specific Veradigm EMR, such as TouchWorks or Sunrise, for Highmark PA?

Klivira integrates via the Veradigm Developer Program, utilizing FHIR R4 APIs and SMART App Launch for modern product lines like TouchWorks EHR and Professional EHR. For Sunrise, we adapt to its specific integration capabilities, ensuring patient context and clinical data are accurately transferred for Highmark prior authorization requests.

What are the primary channels Klivira uses to submit prior authorizations to Highmark?

For medical benefit prior authorizations, Klivira primarily submits to Highmark through Availity Essentials and via X12 278 transactions with supported clearinghouses. Our system is configured to align with Highmark's specific submission requirements and utilization management policies.

Can Klivira help manage prior authorizations for Highmark members across different states like PA, WV, and DE?

Yes, Klivira's platform supports Highmark prior authorization workflows across all its operational states, including Pennsylvania, West Virginia, Delaware, and New York. We account for state-specific regulatory requirements and turnaround time mandates applicable to each region.

Does Klivira write back prior authorization status updates into my Veradigm EMR?

Where configured and supported by the specific Veradigm product line's write-back capabilities, Klivira can update PA status directly into your EMR. This typically includes depositing payer correspondence into Clinical Documentation and routing status updates or follow-up tasks to Veradigm's Tasks/Worklists.

How does Klivira handle Highmark's medical policy guidelines for prior authorization requests?

Klivira's system is designed to align with Highmark's published medical policy and clinical utilization management guidelines. By extracting relevant clinical data from your Veradigm EMR, we help ensure that submitted prior authorization requests meet Highmark's specific criteria for approval.