Veradigm (Allscripts) Medicare Prior Authorization Automation

Optimize your clinic or small hospital's revenue cycle with seamless Veradigm (Allscripts) Medicare prior authorization automation. Klivira integrates directly to simplify the complex landscape of Medicare PAs.

For healthcare organizations utilizing Veradigm (formerly Allscripts) EMRs, navigating Medicare prior authorizations presents a distinct operational challenge. Whether dealing with the limited scope of Original Medicare or the expanded requirements of Medicare Advantage plans, manual processes often lead to administrative burden, delays, and potential revenue loss. Klivira addresses these specific pain points by automating the PA workflow directly from your Veradigm environment.

The Challenge: Veradigm Workflows and Medicare PA Complexity

Clinics and small hospitals relying on Veradigm's portfolio, including TouchWorks and Professional EHR, face a unique set of hurdles when managing Medicare prior authorizations. The manual effort involved in identifying PA requirements, gathering clinical documentation from within the EMR, and then submitting it to various Medicare channels — often involving multiple payer portals or fax for Original Medicare, and diverse ePA methods for Medicare Advantage — consumes significant staff time and diverts resources from patient care. This fragmentation is a primary driver of operational inefficiency.

Navigating Medicare Prior Authorization Channels

Prior authorization requirements for Medicare differ significantly between Original Medicare (Fee-for-Service) and Medicare Advantage (MA) plans. Original Medicare has limited PA requirements, often managed manually through MAC contractor portals such as those for Noridian, NGS, WPS, Palmetto, FCSO, or Novitas. Conversely, Medicare Advantage plans, administered by private insurers, typically have broader PA mandates and may leverage X12 278 transactions, ePA partners, or their proprietary payer portals. Klivira’s platform is engineered to manage these disparate submission pathways efficiently.

Klivira's Direct Integration with Veradigm EMRs

Klivira integrates with Veradigm EMRs (including TouchWorks and Professional EHR) through the Veradigm developer program, leveraging FHIR API capabilities. This robust integration allows Klivira to securely extract necessary patient demographics, clinical notes, and order details from your Veradigm system. By operating as a seamless extension, Klivira eliminates the need for manual data entry into separate PA systems, ensuring data accuracy and reducing the administrative burden on your prior authorization coordinators.

Targeting Key Prior Authorization Workflows for Medicare Patients

Our automation platform is designed to address the PA workflows most relevant to Medicare patients within a Veradigm environment. This includes high-volume, high-cost services such as specialty drug authorizations (e.g., biologics for autoimmune conditions, certain oncology treatments, GLP-1s when covered), advanced imaging (MRI, CT scans), and specific surgical procedures or durable medical equipment. By automating these critical areas, we help ensure timely access to care and reduce claim denials for your Medicare population.

Optimizing Authorization for Specialty Medications and Advanced Diagnostics

For Veradigm users serving Medicare beneficiaries, specialty medications and advanced diagnostic imaging often represent significant PA challenges. Klivira's system can route these complex requests, including those requiring extensive clinical documentation, through the appropriate channels—whether it's an ePA partner supporting NCPDP SCRIPT for specialty pharmacy or direct submission to a MAC portal for specific imaging studies. This targeted approach streamlines the most time-consuming aspects of Medicare prior authorization.

Frequently asked questions

How does Klivira differentiate between Original Medicare and Medicare Advantage prior authorizations?

Klivira's platform is configured to identify the specific payer (Original Medicare or a Medicare Advantage plan) and apply the correct prior authorization rules and submission pathways. For Original Medicare, we route to the relevant MAC contractor. For Medicare Advantage plans, we utilize X12 278, ePA partners, or direct portal automation as appropriate for that specific plan.

What data does Klivira pull from Veradigm for prior authorization requests?

Klivira leverages the Veradigm FHIR API to securely extract patient demographics, insurance information, diagnoses, ordered services, clinical notes, and other relevant documentation required for prior authorization submissions. This data is used to populate the PA request forms accurately and efficiently.

Can Klivira integrate with specific Medicare Administrative Contractor (MAC) portals?

Yes, Klivira's automation capabilities extend to interacting with various MAC contractor portals (e.g., Noridian, NGS, WPS, Palmetto, FCSO, Novitas) to submit and track limited prior authorization requests for Original Medicare. This reduces the manual burden of navigating multiple contractor websites.

How does Klivira support specialty drug prior authorizations for Medicare patients?

Klivira automates the submission of specialty drug prior authorizations by integrating with ePA platforms that support NCPDP SCRIPT standards or by directly interacting with payer portals. This ensures that complex clinical documentation, often required for high-cost biologics or oncology drugs, is accurately and efficiently transmitted for Medicare beneficiaries.

Is Klivira compliant with HIPAA regulations when integrating with Veradigm and Medicare payers?

Klivira maintains strict adherence to HIPAA regulations regarding the handling of PHI and ePHI. Our platform employs robust security measures, including encryption and access controls, to protect patient data during integration with Veradigm EMRs and throughout the prior authorization submission process to Medicare payers. We recommend discussing specific data security protocols with your compliance team.