eMDs Aetna Prior Authorization Automation: Connecting Ambulatory Workflows to Aetna's Channels

Achieving efficient eMDs Aetna prior authorization automation is critical for ambulatory practices managing a high volume of Aetna patients. Klivira provides the integration and workflow orchestration to streamline these complex processes.

Revenue cycle directors and prior authorization coordinators at ambulatory practices using eMDs frequently encounter challenges navigating Aetna's diverse prior authorization submission channels. From medical benefit requests via Availity or X12 278 to pharmacy benefit PAs through ePA partners, manual processes can lead to delays, increased administrative burden, and potential claim denials.

The Challenge of Manual Aetna PA Workflows from eMDs

Ambulatory practices utilizing eMDs often face a fragmented prior authorization process when dealing with Aetna. Extracting necessary clinical documentation from the eMDs EHR and then manually submitting it through Aetna's various portals and channels consumes significant staff time and introduces opportunities for errors that can impact reimbursement.

Seamless Integration: Klivira for eMDs and Aetna Prior Authorization Automation

Klivira connects directly with your CGM eMDs EHR via CGM APIs, enabling automated extraction of patient demographics, clinical notes, and diagnostic results relevant for prior authorization requests. This direct integration eliminates manual data entry from eMDs into external Aetna submission platforms, accelerating the entire PA lifecycle.

Navigating Aetna's Diverse Prior Authorization Channels

Aetna's prior authorization submission requirements vary significantly by benefit category and service type. Klivira's platform is engineered to route requests appropriately, ensuring compliance with Aetna's preferred submission channels for different services.

Klivira supports key Aetna PA submission channels:

**Availity Provider Portal:** For the majority of medical-benefit precertification requests.
**X12 278 Transactions:** Electronic submission for applicable procedure categories via clearinghouses.
**CoverMyMeds and Surescripts:** For outpatient retail pharmacy-benefit prior authorizations.
**CVS Caremark Direct Portal:** For mail-order and case-managed pharmacy scenarios.
**Specialty Pharmacy Workflows:** Routing for specific medical-benefit specialty injectables and infusions.

Addressing Aetna Clinical Policy Bulletins (CPBs) and Medical Necessity

Aetna's medical necessity criteria are detailed in its Clinical Policy Bulletins (CPBs). Klivira assists in mapping clinical data from eMDs to the specific requirements outlined in relevant Aetna CPBs, helping ensure that submitted documentation supports the medical necessity of requested services and treatments, reducing denial risk.

CMS-0057-F Considerations for Aetna Medicare Advantage

For Aetna's Medicare Advantage, Medicaid managed-care, CHIP managed-care, and QHP-on-FFM lines of business, CMS-0057-F introduces new requirements for electronic prior authorization. This includes phased compliance for 72-hour standard and 24-hour expedited decision timeframes. While Klivira's automation capabilities support these compliance efforts, practices should consult with their compliance teams regarding specific implementation timelines and requirements.

Frequently asked questions

How does Klivira connect to eMDs for Aetna prior authorizations?

Klivira integrates with CGM eMDs using its available CGM APIs. This allows for automated, secure extraction of patient clinical data directly from the EHR, populating prior authorization forms and reducing the need for manual data entry into Aetna's submission platforms.

Which Aetna prior authorization channels does Klivira support?

Klivira supports submission to Aetna through its primary channels, including the Availity provider portal for medical benefits, X12 278 transactions for electronic submissions, and ePA partners like CoverMyMeds and Surescripts for pharmacy benefits. This comprehensive coverage ensures requests are routed correctly.

Does Klivira help with Aetna's Clinical Policy Bulletins (CPBs)?

Yes, Klivira helps streamline the process by organizing and presenting clinical data from eMDs in a way that aligns with Aetna's Clinical Policy Bulletins. This assists staff in compiling the necessary documentation to demonstrate medical necessity, supporting compliance with Aetna's criteria.

How does Klivira handle Aetna's pharmacy benefit prior authorizations?

Aetna's pharmacy benefit PAs are administered through CVS Caremark. Klivira facilitates these submissions through established ePA partners like CoverMyMeds and Surescripts for retail prescriptions, and supports workflows for CVS Caremark's direct provider portal for mail-order scenarios.

Is Klivira compliant with CMS-0057-F requirements for Aetna Medicare Advantage?

Klivira's platform is designed to support the electronic prior authorization requirements outlined in CMS-0057-F for impacted payers like Aetna's Medicare Advantage plans. Our automation capabilities contribute to meeting the mandated decision timeframes and electronic data exchange requirements, aiding your compliance efforts.