Achieve eClinicalWorks Clover Health Prior Authorization Automation

Klivira delivers comprehensive eClinicalWorks Clover Health prior authorization automation, streamlining the complex process for Medicare Advantage plans and enhancing revenue cycle efficiency.

Navigating prior authorizations for Clover Health patients within eClinicalWorks presents unique challenges for mid-sized ambulatory practices. The manual burden of submitting and tracking PAs for Medicare Advantage services can divert critical staff resources and delay patient care. Klivira addresses this by automating key steps, ensuring timely submissions and reducing administrative overhead.

The Challenge of eClinicalWorks and Clover Health PAs

Mid-sized ambulatory practices using eClinicalWorks frequently encounter friction when managing prior authorizations for Clover Health's Medicare Advantage members. The need to extract clinical data from eCW and then navigate Clover Health's specific submission requirements, often across disparate systems or manual processes, leads to significant administrative overhead and potential delays in care.

Klivira's Deep Integration with eClinicalWorks

Klivira integrates directly with eClinicalWorks, leveraging its core APIs, including FHIR R4 US Core resources (Patient, ServiceRequest, DocumentReference) via the Developer Portal. Our solution operates as a SMART App Launch application, providing patient context directly from the eCW clinical UI. This approach minimizes context switching for PA coordinators and enables efficient data exchange for authorization requests.

Streamlining Prior Authorizations for Clover Health Medicare Advantage

Clover Health, a prominent Medicare Advantage plan, requires precise documentation and adherence to their medical policies for prior authorizations. Klivira's platform is engineered to connect with payer-specific electronic channels, facilitating the submission of authorization requests. This ensures that PAs for services like specialty medications, advanced imaging, or specific surgical procedures common in Medicare Advantage populations are submitted accurately and efficiently.

Key Prior Authorization Workflows Automated

Automated detection of services requiring prior authorization for Clover Health members.
Extraction of necessary clinical documentation from eClinicalWorks (e.g., Progress Notes, Orders).
Electronic submission of X12 278 equivalent data or direct-to-payer portal submissions.
Automated status checks and updates for submitted Clover Health PAs.
Write-back of authorization status and documents into the eClinicalWorks Patient Hub or Inbox.
Integration with Healow for relevant payer-side data exchange mechanisms.

Ensuring Data Exchange and Compliance Considerations

Klivira's integration architecture supports secure and compliant data exchange, aligning with industry standards. For eClinicalWorks, this includes leveraging FHIR endpoints and considering the role of Healow in broader payer-to-payer data exchange, which is relevant to CMS-0057-F interoperability requirements. Organizations should discuss data flow and compliance implications with their internal teams to ensure adherence to HIPAA and other relevant regulations.

Accelerating Time-to-Care for Clover Health Patients

By automating the prior authorization process between eClinicalWorks and Clover Health, Klivira significantly reduces manual tasks and accelerates approval times. This efficiency translates directly into faster access to necessary medical services for Medicare Advantage beneficiaries, improving patient satisfaction and optimizing revenue cycle performance for ambulatory practices.

Frequently asked questions

How does Klivira integrate with eClinicalWorks for Clover Health PAs?

Klivira integrates with eClinicalWorks primarily through its FHIR R4 APIs, leveraging US Core resources for clinical data extraction. We also utilize SMART App Launch for seamless access from within the eCW clinical UI, providing patient context directly to our platform, and interact with Healow for relevant payer-side data exchange.

What specific Clover Health services can Klivira automate prior authorizations for?

Klivira can automate prior authorizations for a wide range of services requiring approval from Clover Health, particularly those common in Medicare Advantage plans. This includes specialty medications, advanced diagnostic imaging, surgical procedures, and durable medical equipment, streamlining the submission process across diverse service lines.

Does Klivira handle the write-back of PA status into eClinicalWorks?

Yes, Klivira supports write-back capabilities into eClinicalWorks. This includes depositing approved authorization documents into the Patient Hub or Progress Notes and updating PA status within the Inbox or Task Management modules, ensuring a unified view of authorization progress within the EMR.

How does Klivira address Medicare Advantage-specific PA requirements from Clover Health?

Klivira's platform is designed to adapt to payer-specific requirements. For Clover Health's Medicare Advantage plans, this means configuring our system to align with their medical necessity criteria and submission pathways, whether through electronic channels or specific portals, to ensure accurate and compliant authorization requests.

Is Klivira's integration with eCW compliant with FHIR standards?

Yes, Klivira leverages eClinicalWorks' FHIR R4 APIs, adhering to US Core implementation guides for data exchange. Our integration also supports SMART App Launch, which is built upon OAuth 2.0 and OpenID Connect for secure authentication and authorization, aligning with industry interoperability standards.