Optimizing Veradigm (Allscripts) Prior Authorization for Ophthalmology

Navigating High-Volume Ophthalmology PAs within Veradigm EHRs

Ophthalmology prior authorization workflows are dominated by categories such as anti-VEGF intravitreal injections (Eylea, Lucentis, Vabysmo), premium intraocular lenses (IOLs) for cataract surgery, and oculoplastic procedures. These high-volume requests, often recurring, demand a robust and integrated solution within Veradigm's ambulatory platforms like TouchWorks EHR and Professional EHR to prevent treatment delays and revenue leakage.

Key Ophthalmology Prior Authorization Triggers

• Anti-VEGF intravitreal injections for wet AMD, DME, RVO (Aflibercept, Ranibizumab, Faricimab).
• Cataract surgery with premium IOLs or specific lens technologies.
• Glaucoma surgical procedures, including MIGS and traditional interventions.
• Corneal procedures like DSAEK, DMEK, and cross-linking for keratoconus.
• Medically necessary oculoplastic procedures, such as blepharoplasty for visual field impairment.
• Specialty drops requiring prior authorization.

Seamless Integration with Veradigm Developer Program and FHIR APIs

Klivira integrates with Veradigm's modern product lines via the Veradigm Developer Program, leveraging FHIR R4 read APIs for US Core resources including Patient, Encounter, ServiceRequest, and DocumentReference. This allows Klivira to launch as a SMART on FHIR application directly from within the Veradigm clinical UI, providing patient context and streamlining the prior authorization submission process without requiring clinicians to leave their native EMR environment. We utilize available write-back capabilities for DocumentReference to deposit PA packets and Communication resources for status updates directly into the patient chart.

Automating Documentation for Ophthalmology Payer Policies

Payer policies for ophthalmology often align with AAO Preferred Practice Patterns. Klivira's platform is configured to guide users in gathering and organizing required documentation, such as OCT findings, visual acuity reports, and prior treatment responses for anti-VEGF injections. For premium IOLs, documentation of patient acknowledgment for out-of-pocket costs is crucial, while oculoplastic procedures require clear evidence of medical necessity, often including visual field tests and photographs.

Addressing Common Ophthalmology PA Denials Proactively

Ophthalmology practices frequently encounter denials related to biosimilar substitution requirements for anti-VEGF agents or insufficient documentation of prior treatment response for ongoing cycles. Klivira's workflow incorporates logic to identify potential denial triggers, such as gaps in visual field documentation for glaucoma surgery or ptosis repair, and prompts for necessary information before submission, helping to reduce rework and accelerate approvals.

Optimizing Chronic Anti-VEGF Injection Workflows

The chronic nature of anti-VEGF injection cycles demands an efficient re-authorization process. Klivira automates the tracking and submission of periodic re-authorizations, ensuring that ongoing treatments for conditions like wet AMD or DME are not interrupted by lapsed prior approvals. This includes managing step therapy compliance and biosimilar substitution routing based on current payer policies, directly within your Veradigm EMR workflow.