eClinicalWorks BCBS New York Prior Authorization Automation

Klivira streamlines eClinicalWorks BCBS New York prior authorization automation, connecting your eCW EMR data directly with BCBS NY's diverse submission channels.

Navigating prior authorizations for BlueCross BlueShield New York plans from an eClinicalWorks environment presents unique workflow challenges for revenue cycle directors and PA coordinators. The complexity arises from eCW's integration architecture and BCBS NY's specific submission requirements, including portal use and RBM routing. Klivira provides a robust solution to automate and accelerate this critical process.

Klivira's Deep Integration with eClinicalWorks

Klivira integrates directly with eClinicalWorks (eCW) to extract necessary clinical and demographic data for prior authorization submissions. We leverage eCW's FHIR R4 read APIs, covering US Core resources such as Patient, Encounter, Coverage, ServiceRequest, and DocumentReference. This ensures that comprehensive patient context is automatically gathered, reducing manual data entry and improving accuracy at the point of submission.

Prior Authorization Data Flow within eCW

**SMART App Launch:** Klivira operates as a SMART on FHIR application, launching from within the eCW clinical UI to provide patient context directly to our platform.
**Data Extraction:** We pull relevant data from Patient Hub, Progress Notes, Orders, and e-Prescribing modules to build complete PA packets.
**Write-back Capabilities:** Klivira supports write-back to eCW, depositing payer correspondence, status updates, and completed PA documents (e.g., DocumentReference) directly into the patient chart.
**Task Management:** PA-related follow-up items and status changes are routed to eCW's Inbox and Task Management system, ensuring continuity of workflow.

Connecting to BlueCross BlueShield New York's Diverse Channels

BlueCross BlueShield New York (including Excellus and Highmark NY plans) utilizes multiple channels for prior authorization submissions. Klivira's platform is engineered to connect with these diverse pathways, whether for medical or pharmacy PAs. This ensures that submissions are routed correctly the first time, minimizing delays and rework.

BCBS New York Prior Authorization Submission Pathways

**Availity Essentials:** For medical prior authorizations, Klivira connects to Availity Essentials, the primary portal for Empire BCBS NY, automating data submission and status checks.
**Carelon Medical Benefits Management:** For advanced imaging, cardiology, MSK, sleep, and radiation oncology, Klivira routes requests to Carelon Medical Benefits Management (formerly AIM Specialty Health).
**X12 278 Transactions:** Klivira supports X12 278 electronic prior authorization submissions via clearinghouses, providing a standardized channel for medical PA requests.
**CarelonRx:** Pharmacy benefit prior authorizations for BCBS NY are routed through CarelonRx (formerly IngenioRx), ensuring compliant ePA submission for medications.

Leveraging eCW's Interoperability for BCBS NY Workflows

eClinicalWorks' commitment to interoperability, including its Open Interoperability Program and Healow platform, complements Klivira's automation capabilities. The Healow platform's role in payer-to-payer data exchange and CMS-0057-F driven interoperability can be leveraged to enhance the flow of coverage and policy data, further streamlining the eClinicalWorks BCBS New York prior authorization automation process. Klivira's solution is designed to adapt to the specific configuration of your eCW deployment, whether cloud-hosted or self-hosted.

Frequently asked questions

How does Klivira handle the Availity portal for BCBS New York PA submissions from eClinicalWorks?

Klivira automates the submission process to Availity Essentials for BCBS New York medical prior authorizations. Our system extracts the necessary patient and clinical data from eClinicalWorks via FHIR APIs, then populates and submits the request through the Availity platform, reducing manual effort and potential errors.

Does Klivira integrate with eClinicalWorks' Healow platform for PA workflows?

Yes, Klivira is designed to integrate with eClinicalWorks' broader ecosystem, including consideration for the Healow platform's role in patient engagement and payer-side data exchange. This allows for a comprehensive approach to prior authorization, leveraging all available interoperability surfaces within eCW.

Can Klivira manage pharmacy prior authorizations for BCBS New York when using eClinicalWorks?

Absolutely. For pharmacy benefit prior authorizations with BCBS New York, Klivira routes requests through CarelonRx, the in-house Elevance PBM. This ensures that medication-specific PA requirements are met, streamlining the ePA process directly from your eClinicalWorks EMR.

What EMR data does Klivira pull from eClinicalWorks for BCBS New York PA submissions?

Klivira pulls essential patient context, encounter details, coverage information, and service requests from eClinicalWorks using FHIR R4 US Core APIs. This includes data from Patient Hub, Progress Notes, and Orders/e-Prescribing modules, ensuring a comprehensive data set for each BCBS New York prior authorization request.

How does Klivira ensure compliance with New York-specific prior authorization regulations?

Klivira's automation platform is built to align with the operational requirements of New York state insurance regulations, including those from the NY State Department of Financial Services for commercial PAs and NY State DOH for Medicaid managed care. While Klivira automates the submission process, organizations should consult their compliance teams regarding specific regulatory interpretations and obligations.