Optimizing Oracle Health (Cerner) BCBS New York Prior Authorization Automation

The Operational Challenge: Oracle Health (Cerner) and BCBS New York PAs

For health systems utilizing Oracle Health (Cerner), managing prior authorizations for BCBS New York members presents distinct challenges. Care teams frequently encounter **PowerChart context switching**, navigate **fax-heavy workflows**, and experience **payer portal fatigue** when accessing platforms like Availity Essentials or Carelon Medical Benefits Management. This fragmented approach strains revenue cycle operations and can delay patient care.

Klivira's Seamless Integration with Oracle Health (Cerner)

• **SMART on FHIR App Launch:** Klivira integrates as a SMART on FHIR application, launching directly from PowerChart to maintain patient and encounter context, reducing the need for manual data entry.
• **FHIR R4 APIs:** We leverage FHIR R4 APIs for secure, standards-based data exchange, accessing US Core resources such as Coverage, ServiceRequest, MedicationRequest, and DocumentReference.
• **HL7 v2 Interfaces:** For legacy deployments, Klivira supports HL7 v2 interfaces to capture admission, order, and other critical events, ensuring comprehensive workflow coverage.
• **CDS Hooks:** Integrate with Cerner's CDS Hooks at order entry to proactively identify services requiring prior authorization, embedding PA intelligence directly into the clinical workflow.

Navigating BCBS New York's Diverse Prior Authorization Channels

BCBS New York plans, including Excellus and Highmark NY, route prior authorizations through specific channels. Medical PAs for commercial and Medicare Advantage members primarily go via **Availity Essentials**. Specialized services like advanced imaging, cardiology, and musculoskeletal procedures are managed by **Carelon Medical Benefits Management** (formerly AIM Specialty Health). Pharmacy PAs route through **CarelonRx**, the in-house PBM. Klivira centralizes these disparate access points, submitting via X12 278 where applicable and automating portal interactions.

Key Prior Authorization Workflows Automated for BCBS New York

• **Medical & Surgical PAs:** Automated submission and tracking for a wide range of medical and surgical services, including those routed through Availity Essentials.
• **Advanced Imaging & Specialty Procedures:** Streamlined workflows for services requiring review by Carelon Medical Benefits Management.
• **Pharmacy & Specialty Drug PAs:** Direct integration with CarelonRx for efficient processing of pharmacy benefit prior authorizations.
• **X12 278 Submissions:** Leverage electronic data interchange for compliant and rapid submission of prior authorization requests where supported by BCBS New York.

Data Exchange and Regulatory Considerations

Klivira facilitates secure, HIPAA-compliant exchange of ePHI, utilizing FHIR DocumentReference for clinical documentation and Communication resources for status updates. While FHIR write capabilities for PA-relevant resources are continually expanding within Oracle Health (Cerner), Klivira ensures robust data flow and audit trails. Health systems should discuss specific write-back configurations with their IT and compliance teams, aligning with ONC Cures Update API certification status as tracked on CHPL. New York insurance regulations (NY State Department of Financial Services) and CMS-0057-F also establish critical turnaround timeframes that automation helps meet.

Accelerating Time-to-Care and Operational Efficiency

By automating the complexities of Oracle Health (Cerner) and BCBS New York prior authorizations, Klivira significantly reduces administrative burden. This allows PA coordinators to focus on complex cases, minimizes manual errors, and improves overall throughput. The result is faster PA approvals, reduced denial rates, and a more efficient revenue cycle, ultimately benefiting patient access to necessary care.