Streamlining DrChrono UnitedHealthcare Prior Authorization Automation

DrChrono and UnitedHealthcare: A Unique PA Challenge

DrChrono's focus on efficient, patient-centric care in ambulatory settings can be undermined by the manual demands of UnitedHealthcare's prior authorization requirements. Managing UHC's varied policies across medical, pharmacy, and specialty benefits, coupled with distinct submission portals and criteria, presents a significant operational overhead for practices.

Klivira's Seamless Integration with DrChrono for UHC Workflows

Klivira connects directly with DrChrono via its robust API and FHIR endpoints, allowing prior authorization requests to originate within the EMR. This integration eliminates duplicate data entry and ensures that clinical documentation required by UnitedHealthcare is automatically sourced from the patient's chart, accelerating the submission process and enhancing accuracy.

Navigating UnitedHealthcare's Diverse Prior Authorization Channels from DrChrono

• **UHCprovider.com Portal Submissions:** Klivira automates submissions to the UnitedHealthcare Provider Portal for medical benefit prior authorizations, including advance notifications and procedure-specific requests.
• **X12 278 Transactions:** For procedures supporting electronic data interchange, Klivira facilitates X12 278 transactions via clearinghouses, ensuring compliance with UHC's electronic submission preferences.
• **Pharmacy ePA via OptumRx, CoverMyMeds, and Surescripts:** Klivira integrates with OptumRx's provider PA system and ePA partners like CoverMyMeds and Surescripts for efficient processing of pharmacy benefit prior authorizations.
• **Specialty Drug PAs through Optum Specialty Pharmacy:** We manage the complexities of specialty injectables and infusions by routing requests through Optum Specialty Pharmacy's designated channels, adhering to medical and pharmacy benefit splits and site-of-care policies.

Automating Medical and Specialty Drug PAs for UnitedHealthcare

Klivira's platform is engineered to handle UnitedHealthcare's specific PA requirements for high-volume and high-cost services. This includes automating prior authorizations for advanced imaging, surgical procedures, and specialty medications often governed by UHC's Medical Policy Library, which references criteria from sources like MCG and the NCCN compendium for oncology.

Addressing UHC's Policy Complexity and Turnaround Times

Klivira helps DrChrono users navigate UnitedHealthcare's intricate medical necessity criteria and state-specific turnaround time mandates. We factor in payer-published service-level targets and compliance considerations for CMS-0057-F for UHC's Medicare Advantage and Community Plan lines, ensuring timely submissions and follow-ups to meet regulatory requirements and NCQA UM accreditation standards.

Leveraging Da Vinci Project Standards for Future-Proofing

UnitedHealthcare is a public participant in the HL7 Da Vinci Project, advocating for standards like PAS (Prior Authorization Support) IG, CRD (Coverage Requirements Discovery), and DTR (Documentation Templates and Rules). Klivira monitors and aligns with these evolving electronic prior authorization standards to ensure our integration with DrChrono remains future-proofed for UHC's digital initiatives.

Beyond Submission: Denial Management and Appeals

Klivira goes beyond initial submission, providing tools to track UnitedHealthcare denial reasons, which are often communicated via X12 277/835 transactions or portal updates. Our system supports the preparation for UHC's multi-level appeal pathways, including peer-to-peer reviews for clinical denials, helping DrChrono practices minimize revenue leakage and improve patient access to care.