Streamline DrChrono Highmark Prior Authorization Automation

Klivira delivers robust DrChrono Highmark prior authorization automation, specifically designed to reduce administrative burden for ambulatory and concierge practices utilizing DrChrono EHR.

For practices leveraging DrChrono EHR, navigating the prior authorization landscape with Highmark across Pennsylvania, West Virginia, Delaware, and New York presents unique operational challenges. The manual submission processes, diverse payer channels, and varying state regulations can significantly impact revenue cycle efficiency and staff productivity. Klivira addresses these complexities by integrating directly with your DrChrono environment to automate key PA workflows for Highmark.

The Challenge of Highmark Prior Authorizations from DrChrono

Small ambulatory and concierge practices using DrChrono EHR often face a disproportionate burden when managing prior authorizations for Highmark. This involves manual data entry into the Availity Essentials portal for medical PA, coordinating X12 278 transactions, and verifying specific pharmacy benefit manager (PBM) relationships for drug-related requests. The fragmented nature of these submissions, coupled with state-specific turnaround time mandates across Highmark's service areas (PA, WV, DE, NY), creates a significant administrative overhead.

Klivira's Integration with DrChrono EHR

Klivira integrates directly with DrChrono EHR via the DrChrono API and FHIR endpoints. This deep integration allows Klivira to securely extract necessary patient demographics, clinical documentation, and order details directly from the patient chart. By leveraging these established integration surfaces, Klivira minimizes the need for staff to manually re-key information, ensuring data accuracy and accelerating the initiation of prior authorization requests.

Automating Highmark PA Submissions

Klivira streamlines the prior authorization submission process for Highmark across its various channels. For medical benefit PAs, Klivira automates data submission to Highmark via Availity Essentials and facilitates X12 278 transactions through your clearinghouse for impacted procedures. For pharmacy PAs, Klivira helps manage the complexity of Highmark's PBM relationships, which require verification for specific plans. This multi-channel approach ensures that requests are routed correctly and efficiently, reducing delays and improving turnaround times.

Navigating Highmark's Medical Policies and Specialty Vendors

Klivira incorporates Highmark's medical policy and clinical utilization management guideline libraries, accessible via its provider site, into the automation workflow. This enables proactive identification of documentation requirements. Furthermore, for advanced imaging, cardiology, musculoskeletal (MSK), and radiation oncology services, Klivira accounts for Highmark's practice of routing specific clinical domains through specialty benefit-management vendors, whose current scope requires verification at each review cycle.

Compliance and Turnaround Time Considerations for Highmark

Klivira's automation platform is designed with an understanding of the varying state-mandated minimum turnaround times across Highmark's operating states (PA, WV, DE, NY). For Highmark's Medicare Advantage, Medicaid managed-care, and any Qualified Health Plan (QHP) on the Federally Facilitated Marketplace (FFM) lines, Klivira also considers the applicability of CMS-0057-F. Practices should discuss these regulatory considerations with their compliance teams.

Frequently asked questions

How does Klivira integrate with DrChrono EHR for prior authorizations?

Klivira integrates with DrChrono EHR through its robust API and FHIR endpoints. This allows our platform to securely pull necessary patient data, clinical notes, and order details directly from the EMR, eliminating the need for manual data entry into the prior authorization request.

What Highmark prior authorization submission channels does Klivira support?

Klivira supports Highmark's primary medical PA submission channels, including automation through Availity Essentials and facilitation of X12 278 transactions via your clearinghouse. For pharmacy PAs, Klivira helps manage the varied PBM relationships, which require verification for specific Highmark plans.

Can Klivira handle Highmark's requirements for specialty services like imaging?

Yes, Klivira's platform is designed to accommodate Highmark's routing of advanced imaging, cardiology, musculoskeletal, and radiation oncology services through specialty benefit-management vendors. While the specific vendor scope requires verification, Klivira helps streamline the submission process for these specialized requests.

Does Klivira help with Highmark's utilization management policy adherence?

Klivira integrates access to Highmark's medical policy and clinical utilization management guideline libraries, which are published on its provider site. This functionality assists practices in proactively identifying and gathering the required clinical documentation to support prior authorization requests, improving the likelihood of approval.

How does Klivira address state-specific PA rules for Highmark?

Klivira's system accounts for the varying state-mandated minimum turnaround times for prior authorizations across Highmark's service areas in Pennsylvania, West Virginia, Delaware, and New York. This helps practices manage expectations and prioritize urgent requests in compliance with local regulations.