Accelerating athenahealth BCBS Texas Prior Authorization Automation

Klivira delivers robust athenahealth BCBS Texas prior authorization automation, integrating directly with your EMR to manage complex payer requirements efficiently.

For ambulatory practices and multi-specialty groups utilizing athenahealth, navigating BCBS Texas prior authorizations presents unique challenges, from managing payer-rule churn to the significant staff time spent on portal logins. Klivira addresses these operational friction points by automating the end-to-end PA process, ensuring a seamless experience for your revenue cycle teams.

The Challenge of BCBS Texas Prior Authorizations from athenahealth

Submitting prior authorizations to BCBS Texas (an HCSC-owned plan) from within athenahealth often involves toggling between the EMR and external payer portals like Availity Essentials. This manual workflow for medical benefit precertifications, coupled with separate processes for pharmacy benefits via Prime Therapeutics, consumes valuable staff time and increases the risk of delays or denials due to inconsistent data entry or missed requirements.

Klivira's Deep Integration with athenahealth for Optimized Workflows

Klivira integrates with athenahealth using a combination of FHIR R4 and athena-proprietary APIs, enabling a unified prior authorization experience. Our platform leverages SMART App Launch for contextual access within athenaOne, allowing your teams to initiate and manage PA requests without leaving the clinical chart. This includes reading critical patient data from US Core resources and writing back authorization statuses and documentation.

Streamlining BCBS Texas Submission Channels

**Medical Benefit PA:** Automate submissions for commercial and Medicare Advantage plans, routing through Availity Essentials and the BCBSTX provider portal, including X12 278 transactions for eligible procedures.
**Pharmacy Benefit PA:** Facilitate electronic prior authorizations (ePA) for retail pharmacy benefits through Prime Therapeutics, integrating with CoverMyMeds and Surescripts ePA for prescriber-initiated workflows.
**Specialty Drug PA:** Manage complex specialty injectable and medical-benefit medications through appropriate BCBS Texas medical PA channels, while pharmacy-benefit specialty drugs are routed via Prime Therapeutics.
**Advanced Imaging & Specialty Services:** Prepare and submit authorizations for services often routed through specialty benefit-management vendors, ensuring all necessary clinical documentation is attached.
**Texas Medicaid (STAR/STAR Kids):** Support PA workflows for Texas Medicaid managed care, adhering to Texas Health and Human Services contracted program rules layered on BCBS Texas's UM operations.

Automating Policy Adherence and Compliance for BCBSTX

Klivira incorporates BCBS Texas medical policies and clinical utilization management guidelines, accessible via Availity, directly into the automation workflow. This ensures that submitted requests align with payer criteria, whether HCSC-developed, MCG-based, or NCCN-compendium-based. Our system also helps your organization prepare for compliance with mandates like CMS-0057-F, which impacts Medicare Advantage and Texas Medicaid managed-care plans, by standardizing PA decision timeframes.

Seamless Prior Authorization Documentation in athenaOne

Klivira's integration supports critical write-back capabilities to athenaOne. This means authorization numbers, status updates, and supporting documentation can be automatically deposited into the patient's Chart, update relevant Inbox/Task queues, or be added to Clinical Documents. This ensures a comprehensive, auditable record of all prior authorization activities within your athenahealth environment, reducing manual data entry and improving data accuracy.

Frequently asked questions

How does Klivira handle different BCBS Texas PA channels?

Klivira connects to multiple BCBS Texas PA channels, including the Availity Essentials portal for medical benefits and Prime Therapeutics for pharmacy benefits via ePA partners like CoverMyMeds and Surescripts. This ensures that whether the PA is for a medical procedure or a prescription, it is routed through the correct pathway for efficient processing.

Can Klivira integrate with athenahealth for both clinical and billing workflows?

Yes, Klivira integrates with both athenaClinicals (EMR) and athenaCollector (PM/billing) modules. We leverage athena's FHIR and legacy APIs to pull clinical context for PA initiation and write back authorization details, impacting both the clinical chart and administrative workflows related to billing and claims.

What kind of clinical data does Klivira access from athenahealth for PA?

Klivira accesses relevant clinical data from athenahealth via FHIR R4 US Core resources, including Patient, Encounter, Coverage, ServiceRequest, MedicationRequest, and DocumentReference. This data is used to populate PA requests with the necessary clinical context, reducing manual data extraction and improving accuracy.

How does Klivira help with BCBS Texas's specific policy requirements?

Klivira incorporates the latest BCBS Texas medical policies and clinical UM guidelines into its automation logic. This includes policies published on the BCBSTX provider site via Availity. Our system helps ensure that PA requests are submitted with the correct documentation and clinical rationale, aligning with payer criteria to minimize denials.

Is Klivira compatible with athenahealth's SMART App Launch?

Yes, Klivira supports SMART App Launch, enabling our application to be launched directly from within athenaOne with patient context. This provides a seamless user experience for your staff, allowing them to initiate and manage prior authorizations without navigating away from the patient's chart.