Streamlining TruBridge (CPSI) Highmark Prior Authorization Automation

Klivira delivers intelligent TruBridge (CPSI) Highmark prior authorization automation, specifically designed for the operational realities of rural and community hospitals.

For revenue cycle directors and prior authorization coordinators at facilities leveraging TruBridge (CPSI), navigating Highmark's diverse prior authorization requirements can introduce significant workflow friction. From medical benefit PAs routed through Availity Essentials to specialty benefit-management vendor portals and the intricacies of state-specific regulations across Pennsylvania, West Virginia, Delaware, and New York, manual processes are a primary driver of delays and denials.

Klivira Integration with TruBridge (CPSI)

Klivira integrates directly with TruBridge (CPSI) via the TruBridge API, enabling seamless data exchange for prior authorization requests. This deep integration allows Klivira to extract necessary clinical and demographic information from the Evident EHR, pre-populating PA forms and reducing the manual effort typically associated with initiating authorizations for Highmark services.

Navigating Highmark's Diverse Submission Channels

Highmark, a prominent BCBS plan across PA, WV, DE, and NY, utilizes multiple channels for prior authorization submissions. For medical benefit PAs (commercial and Medicare Advantage), Highmark primarily routes requests through Availity Essentials. Klivira automates the submission process to Availity, while also supporting X12 278 transactions via clearinghouses for impacted procedures, ensuring comprehensive coverage of Highmark's preferred intake methods.

Specialty Benefit Management and Pharmacy PA

Like many major commercial plans, Highmark directs specific clinical domains such as advanced imaging, cardiology, musculoskeletal, and radiation oncology through specialty benefit-management vendors. Klivira's platform intelligently routes these requests to the appropriate vendor portal. For pharmacy benefit PAs, Klivira supports the necessary workflows, noting that Highmark's PBM relationship should be verified at the point of use for precise routing.

Streamlining Policy Access and Regulatory Compliance

Highmark publishes its medical policy and clinical utilization management guideline libraries through its provider site. Klivira's automation incorporates these policies to help ensure submissions are aligned with current requirements. Furthermore, Klivira assists in navigating the regulatory landscape, including state-mandated minimum turnaround times across Highmark's service areas and the applicability of CMS-0057-F for Highmark's MA, Medicaid managed-care, and QHP-on-FFM lines of business.

Key Benefits for TruBridge (CPSI) Users with Highmark

Automated data extraction from Evident EHR to populate Highmark PA requests.
Intelligent routing to Availity Essentials, X12 278, and specialty vendor portals.
Centralized tracking and management of all Highmark prior authorizations.
Reduced manual administrative burden for PA coordinators.
Improved adherence to Highmark's medical policies and UM guidelines.
Support for compliance considerations under CMS-0057-F for relevant Highmark plans.

Optimizing Workflow for Rural and Community Hospitals

Klivira understands the unique resource constraints faced by rural and community hospitals using TruBridge. Our platform is designed to maximize efficiency, allowing your team to focus on patient care rather than the complexities of Highmark's varied prior authorization processes. By automating routine tasks, we help reduce turnaround times and improve authorization success rates, directly impacting your revenue cycle.

Frequently asked questions

How does Klivira integrate with TruBridge (CPSI) for prior authorizations?

Klivira integrates with TruBridge (CPSI) through its TruBridge API. This allows our platform to securely extract necessary patient data, clinical notes, and order details from the Evident EHR to automatically populate prior authorization request forms, minimizing manual data entry.

Does Klivira automate submissions to Highmark's Availity Essentials portal?

Yes, Klivira automates the submission of medical benefit prior authorizations directly to Highmark's Availity Essentials portal. This includes pre-populating forms and submitting required documentation, streamlining a primary channel for Highmark PA requests.

How does Klivira handle Highmark's specialty benefit-management vendors for services like imaging?

Klivira intelligently identifies and routes prior authorization requests for specific clinical domains, such as advanced imaging or cardiology, to Highmark's designated specialty benefit-management vendors. Our platform manages these varied submission pathways to ensure requests reach the correct destination.

Does Klivira help with Highmark's pharmacy prior authorizations?

Klivira supports the workflow for pharmacy prior authorizations by facilitating the necessary data exchange. Given that Highmark's PBM relationships can vary, we ensure the process is adaptable while recommending verification of the specific PBM at the time of service.

What is Klivira's approach to Highmark's state-specific PA rules and CMS-0057-F?

Klivira's platform is designed to accommodate state-specific prior authorization rules, including turnaround time mandates across Highmark's service areas (PA, WV, DE, NY). We also consider the implications of CMS-0057-F for Highmark's applicable lines of business, such as Medicare Advantage and Medicaid managed-care, to support compliant workflows.