Powering Veradigm (Allscripts) Humana Prior Authorization Automation

Klivira delivers robust Veradigm (Allscripts) Humana prior authorization automation, directly addressing the complexities of payer requirements and EMR workflows. Our platform streamlines the entire PA lifecycle, from order initiation to decision notification.

Revenue cycle and prior authorization teams face significant operational burdens managing authorizations for Humana patients within Veradigm (Allscripts) EMR environments. The need to navigate disparate payer portals, manually extract clinical data, and track status updates consumes valuable resources. Klivira provides a purpose-built solution to alleviate these challenges.

Addressing the Veradigm (Allscripts) to Humana PA Workflow Challenge

Navigating prior authorizations for Humana patients from within Veradigm's diverse EMR portfolio—including TouchWorks EHR, Professional EHR, and Sunrise—presents unique challenges. Clinicians initiate orders in the EMR, but the subsequent PA workflow often diverges into manual data extraction, portal submissions via Availity, and tracking across disparate systems. This fragmentation introduces delays and increases administrative overhead.

Klivira's Integration with Veradigm (Allscripts) EMRs

Klivira integrates with Veradigm EMRs through the Veradigm Developer Program, leveraging FHIR R4 APIs for US Core resources and SMART App Launch for seamless clinical UI integration. This connection enables direct access to patient demographics, encounters, orders, and clinical documentation, minimizing manual chart abstraction. We support both ambulatory lines like TouchWorks EHR and Professional EHR, and the Sunrise inpatient platform, accounting for product-line-specific integration surfaces.

Streamlined Humana Prior Authorization Submissions

Klivira automates the submission of prior authorizations to Humana, leveraging established channels such as X12 278 transactions and direct integration with the Availity Essentials portal. For pharmacy benefits, our system routes requests through Humana's PBM operations and ePA partners like CoverMyMeds and Surescripts. This multi-channel approach ensures comprehensive coverage for medical, pharmacy, and specialty drug authorizations.

Key Prior Authorization Workflows Automated for Humana

Medical benefit authorizations for imaging, surgical procedures, and specialty medications requiring site-of-care review.
Pharmacy benefit prior authorizations, including specialty injectables managed by CenterWell Specialty Pharmacy.
Medicare Advantage (MA) pre-service determinations, adhering to CMS-0057-F requirements and statutory timeframes.
Inpatient admission notifications and concurrent review intake, following Humana's documented pathways.
Automated retrieval and processing of Humana's utilization management policies and coverage determinations.

Navigating Humana's Medicare Advantage Landscape

As a dominant Medicare Advantage carrier, Humana's PA processes are significantly shaped by CMS regulations, including CMS-0057-F. Klivira's platform is designed to align with these evolving requirements, facilitating compliance and optimizing workflows for MA lines of business. Our system helps manage the specific documentation needs for services under NCDs and LCDs, critical for Humana MA coverage.

Enhanced Visibility and Denial Prevention

Klivira provides real-time status updates from Humana, integrating denial reasons returned via X12 277/835 or Availity portal updates directly into your workflow. This visibility enables proactive intervention, whether for insufficient documentation, medical necessity, or step therapy requirements. Our system supports the preparation for Humana's appeal pathways, including the CMS-mandated 5-level appeal structure for Medicare Advantage organization determinations.

Frequently asked questions

How does Klivira handle the different Veradigm (Allscripts) EMR products for Humana PA?

Klivira's integration strategy accounts for the distinct Veradigm product lines, including TouchWorks EHR, Professional EHR, Sunrise, and Practice Fusion. We leverage the Veradigm Developer Program and FHIR APIs, tailoring our connectivity to each product's specific integration surface and chart anatomy to ensure accurate data exchange for Humana PA requests.

What Humana PA submission channels does Klivira support?

Klivira supports multiple Humana PA submission channels. This includes X12 278 electronic transactions, direct integration with the Availity Essentials provider portal, and ePA partners like CoverMyMeds and Surescripts for pharmacy benefits. Our platform ensures requests are routed through the most efficient and compliant pathway.

Can Klivira help with Humana Medicare Advantage prior authorizations?

Yes, Klivira is specifically designed to manage Humana Medicare Advantage prior authorizations. We align with CMS-0057-F requirements and integrate relevant NCD/LCD criteria to streamline submissions. Our system helps ensure that documentation supports Humana's coverage policies, which must adhere to Original Medicare rules for MA plans.

How does Klivira access Humana's medical policies and coverage criteria?

Klivira integrates with Humana's publicly available resources to access medical policies and coverage determination documents published on their provider site. This allows our system to reference specific policy numbers and effective dates, ensuring that prior authorization requests are aligned with Humana-developed, MCG-based, or NCCN-compendium-based criteria where applicable.

What kind of data can Klivira pull from Veradigm (Allscripts) for Humana PA?

Leveraging Veradigm's FHIR R4 APIs, Klivira can extract critical PA-relevant data, including patient demographics, encounter details, coverage information, service requests, medication orders, and clinical documentation. This comprehensive data capture minimizes manual entry and supports the creation of complete, evidence-based prior authorization packets for Humana.