Streamlining ChartLogic Medicare Prior Authorization Automation

For specialty ambulatory practices utilizing ChartLogic, Klivira delivers robust ChartLogic Medicare prior authorization automation, reducing manual effort and accelerating approvals.

Navigating prior authorizations for Original Medicare members from within ChartLogic presents unique challenges. While Original Medicare's PA scope is limited compared to Medicare Advantage, specific services like Durable Medical Equipment (DME) or certain outpatient procedures still mandate authorization. Revenue cycle directors and prior authorization coordinators face the burden of identifying the correct Medicare Administrative Contractor (MAC) jurisdiction, accessing disparate MAC portals, and manually cross-referencing CMS National Coverage Determinations (NCDs) and MAC-specific Local Coverage Determinations (LCDs).

Connecting Klivira with ChartLogic Workflows

Klivira integrates directly with ChartLogic via the ChartLogic API, enabling seamless data exchange for prior authorization requests. This direct connection eliminates manual data entry, reducing transcription errors and improving efficiency for specialty ambulatory practices. Patient demographics, clinical notes, and order details flow securely from ChartLogic to Klivira, initiating the PA process without requiring staff to leave their native EMR environment.

Targeted Prior Authorization for Original Medicare Services

While Original Medicare's prior authorization requirements are specific and not as broad as commercial plans, they are critical for compliance and reimbursement. Klivira's platform is configured to address these targeted programs, ensuring that ChartLogic users can efficiently manage the authorizations that do apply. Our system identifies the responsible Medicare Administrative Contractor (MAC) for the provider's jurisdiction, routing requests to the correct entity.

Key Original Medicare Prior Authorization Programs Supported:

Outpatient Department services prior authorization for specific services (CMS PA model for hospital outpatient services).
Durable Medical Equipment (DME) prior authorization, including PMD demonstration and post-demo expanded lists.
Repetitive Scheduled Non-Emergent Ambulance Transport prior authorization in specific states.
Specific home health, hospice, and post-acute services requiring prior authorization or notification.

MAC-Aware Routing and Policy Logic for ChartLogic Users

Klivira's intelligence layer incorporates the intricacies of Medicare Administrative Contractors (MACs) such as Noridian, NGS, WPS, Palmetto, FCSO, and Novitas. For ChartLogic users, this means prior authorization requests are automatically directed to the correct MAC portal and jurisdiction. Furthermore, our platform leverages NCDs and MAC-published LCDs, referencing specific NCD numbers or LCD IDs, MAC jurisdiction, and effective dates to ensure policy adherence and support accurate submissions.

Addressing Medicare Part D Pharmacy Prior Authorizations

For ChartLogic practices prescribing medications covered under Medicare Part D, Klivira facilitates pharmacy prior authorizations. While Part D plans are administered by commercial insurers as private contractors, they operate under CMS-approved formularies and step-therapy protocols. Klivira supports these ePA workflows, helping specialty practices manage authorizations for high-cost specialty drugs that often fall under Part D requirements, ensuring compliance with plan-specific rules.

Frequently asked questions

How does Klivira integrate with ChartLogic for Medicare prior authorizations?

Klivira integrates directly with ChartLogic through its robust ChartLogic API. This connection allows for the secure and automated exchange of patient data, clinical documentation, and order details, streamlining the prior authorization submission process without requiring manual data entry or context-switching from the EMR.

Does Klivira handle prior authorizations for all Medicare services?

Klivira focuses on the specific services that require prior authorization under Original Medicare (Parts A and B), such as certain Outpatient Department services, DME, and specific transport. For Medicare Part D pharmacy PAs, Klivira supports routing requests to the commercial insurers who administer these plans. Medicare Advantage plans, while part of the broader Medicare program, have expanded PA requirements and are handled as distinct payer entities.

How does Klivira manage different Medicare Administrative Contractors (MACs)?

Klivira maintains an up-to-date knowledge base of Medicare Administrative Contractors (MACs) and their respective jurisdictions (e.g., Noridian, NGS, WPS). Our platform automatically identifies the correct MAC for a provider's location and service type, ensuring that prior authorization requests are routed to the appropriate contractor for review, aligning with per-jurisdiction submission specifics.

What role do NCDs and LCDs play in Klivira's Medicare PA process?

Klivira incorporates CMS National Coverage Determinations (NCDs) and MAC-specific Local Coverage Determinations (LCDs) into its policy logic. This ensures that prior authorization requests from ChartLogic users are aligned with current medical necessity criteria, referencing specific policy numbers, MAC jurisdictions, and effective dates to support compliant and successful submissions.

Is the CMS-0057-F rule applicable to Original Medicare PA through Klivira?

The CMS-0057-F rule primarily targets Medicare Advantage, Medicaid managed care, CHIP, and QHP-on-FFM lines of business. Its applicability to Traditional (Original) Medicare is limited. Klivira adheres to the specific timeframes and requirements documented for each distinct Original Medicare prior authorization program.