athenahealth BCBS New York Prior Authorization Automation

Klivira provides a robust solution for athenahealth BCBS New York prior authorization automation, directly addressing the complexities faced by ambulatory practices and multi-specialty groups.

Navigating prior authorizations for BCBS New York plans from within athenahealth presents unique operational challenges. From managing payer-rule churn to the significant staff time spent on portal logins, manual PA processes can impede patient care and strain revenue cycles. Klivira integrates directly with athenahealth to streamline these critical workflows.

The Challenge: Manual Prior Authorizations with BCBS New York from athenahealth

Ambulatory practices and physician groups utilizing athenahealth frequently encounter inefficiencies when processing prior authorizations for BCBS New York. The manual process involves navigating various submission channels, including the Availity portal for medical PA and CarelonRx for pharmacy PA, often leading to fragmented workflows and increased administrative burden. This complexity is compounded by the ongoing churn in payer rules and the necessity for staff to repeatedly log into multiple payer portals.

Klivira's Integration with athenahealth for Enhanced Efficiency

Klivira leverages athenahealth's cloud-native architecture and robust API surface to embed prior authorization automation directly into clinical workflows. Our integration utilizes FHIR R4 APIs for reading clinical context, including Patient, Encounter, and ServiceRequest resources, ensuring that necessary data is automatically extracted. For interactive workflows, we support SMART App Launch from within athenaOne, providing patient context and a seamless user experience. Klivira also supports write-back capabilities, depositing authorization packets as clinical documents and updating task queues within athenaOne's Inbox, minimizing context switching for PA coordinators.

Navigating BCBS New York's Diverse Prior Authorization Landscape

BCBS New York plans, including Excellus and Highmark NY, route medical prior authorizations through platforms like Availity Essentials. Advanced imaging, cardiology, MSK, sleep, and radiation oncology services are typically managed by Carelon Medical Benefits Management. Pharmacy prior authorizations are routed through CarelonRx, the in-house Elevance PBM. Klivira's platform is engineered to connect with these diverse channels, including X12 278 transactions via clearinghouses, to provide a unified submission experience. We also account for the state-specific utilization management policies published by Empire BlueCross BlueShield, which align with the Elevance corporate framework but include New York-specific variations.

Automating Key PA Workflows for BCBS New York Members

Klivira's automation solution addresses critical prior authorization workflows relevant to athenahealth practices serving BCBS New York members. This includes: automating submissions for advanced imaging services routed through Carelon MBM, streamlining pharmacy PA for specialty drugs via CarelonRx, and managing general medical and surgical authorizations. By automating the data extraction from athenahealth and intelligently routing requests to the correct BCBS NY channel, Klivira reduces manual data entry and accelerates the prior authorization process.

Compliance and Turnaround Time Considerations

Prior authorization turnaround times for BCBS New York plans are governed by multiple regulatory frameworks. Commercial PA timeframes fall under New York State Department of Financial Services regulations. For Medicare Advantage and Medicaid managed-care plans, CMS-0057-F and state-specific Medicaid contracts apply. Klivira's platform helps organizations manage these timelines by providing clear status tracking and facilitating timely submissions, aiding in compliance efforts. Organizations should discuss specific compliance requirements with their internal compliance teams.

Secure and Scalable Data Exchange

Klivira's integration with athenahealth ensures secure exchange of PHI, adhering to HIPAA standards. Leveraging athenahealth's OAuth 2.0 authentication baseline and tenant-aware token endpoints, our platform maintains data integrity and confidentiality. As a cloud-native solution, Klivira offers scalability to support the varying demands of ambulatory practices and multi-specialty groups, ensuring consistent performance regardless of transaction volume.

Frequently asked questions

How does Klivira integrate with athenahealth for prior authorizations?

Klivira integrates with athenahealth primarily through its FHIR R4 APIs and legacy REST APIs, supporting SMART App Launch for contextual workflows. This allows for automated extraction of patient and clinical data, and write-back capabilities to update the athenaOne chart, inbox, and documents with PA status and approvals.

Which BCBS New York plans does Klivira support for prior authorizations?

Klivira supports prior authorization workflows for all BCBS New York plans, including Excellus and Highmark NY. This covers commercial, Medicare Advantage, and Medicaid managed-care lines, by connecting to their respective submission channels like Availity Essentials, Carelon Medical Benefits Management, and CarelonRx.

Can Klivira handle pharmacy prior authorizations for BCBS New York?

Yes, Klivira's platform integrates with CarelonRx (formerly IngenioRx), the PBM for BCBS New York plans, to automate pharmacy prior authorizations. This streamlines the submission process for specialty drugs and other medications requiring ePA.

How does Klivira address different payer policies for BCBS New York?

Klivira's system is designed to adapt to the specific utilization management policies published by Empire BlueCross BlueShield, which incorporate New York-specific variations. Our platform helps ensure that submissions align with the correct policy requirements for each service or medication.

What kind of prior authorization data can be written back to athenahealth?

Klivira supports writing back key prior authorization artifacts to athenahealth, including the authorization number, approval/denial status, and the full PA packet as a clinical document. Updates can also be routed to athenaOne's Inbox or Task queues to inform staff of PA progress or required follow-up actions.