Optimizing Prior Authorization with eMDs and Change Healthcare Clearinghouse
Klivira streamlines prior authorization processes at the intersection of your eMDs EMR and the Change Healthcare Clearinghouse, ensuring efficient data exchange and accelerated approvals for ambulatory practices.
Revenue cycle directors and prior authorization coordinators at ambulatory practices face significant challenges managing PAs, especially when coordinating data between their EMR and clearinghouse. Manual workflows introduce delays, increase administrative burden, and contribute to higher denial rates. Klivira addresses these inefficiencies by automating critical steps in the eMDs Change Healthcare clearinghouse workflow.
The eMDs Prior Authorization Landscape
eMDs (CGM eMDs), including its Solution Series, Lytec, and Medisoft offerings, is a robust ambulatory EHR. While it facilitates clinical documentation, order entry, and often integrates for basic eligibility checks (X12 270/271) via clearinghouses like Change Healthcare, complex prior authorization workflows typically remain a manual adjunct. Users often identify PA requirements during order entry or scheduling, necessitating navigation to external portals or initiation of faxes.
Leveraging CGM APIs for Seamless Integration with eMDs
Klivira integrates directly with eMDs via its secure CGM APIs. This integration allows for the programmatic extraction of essential clinical and administrative data directly from patient charts. By leveraging these APIs, Klivira accesses necessary information—such as patient demographics, diagnosis codes (ICD-10), procedure codes (CPT/HCPCS), and relevant clinical notes—without manual data entry or screen scraping from the eMDs Solution Series or Lytec/Medisoft interfaces.
Klivira's Role in the Change Healthcare Clearinghouse Workflow
Change Healthcare (Optum Change Healthcare) is a critical component for eligibility verification (X12 270/271) and claims submission (X12 837). For prior authorization, the HIPAA X12 278 transaction set is the standard. Klivira automates the generation and submission of X12 278 requests, utilizing the clinical data pulled from eMDs, directly through the Change Healthcare clearinghouse or to payers supporting direct ePA, ensuring accurate, compliant, and timely submission of authorization requests.
Data Exchange: What Klivira Leverages from eMDs
- Patient demographics (name, DOB, insurance ID, contact information)
- Ordering and rendering provider details
- Service details (CPT/HCPCS codes, requested dates of service, facility information)
- Diagnosis codes (ICD-10) and associated clinical documentation
- Relevant clinical notes, lab results, and imaging reports
- Payer information from the patient's active insurance policy
Closing the Loop: Status Updates and EMR Integration
Klivira not only submits authorizations but also actively monitors their status. As X12 278 responses are received (or direct payer portal updates are processed), Klivira pushes these authorization status updates and decision letters directly back into the eMDs system. This ensures that prior authorization coordinators and billing staff have real-time visibility into approval statuses directly within their familiar eMDs environment, reducing the need to toggle between systems and supporting timely appeals.
Key Benefits for Ambulatory Practices
- Reduced administrative burden on prior authorization coordinators and clinical staff.
- Accelerated prior authorization turnaround times and improved service delivery.
- Improved clean claim rates and a significant reduction in authorization-related denials.
- Enhanced visibility into real-time PA status directly within the eMDs interface.
- Streamlined compliance with payer-specific authorization requirements and Da Vinci PAS.
- Optimized revenue cycle performance and increased cash flow for ambulatory services.
Frequently asked questions
How does Klivira access patient data from eMDs for prior authorization?
Klivira integrates with eMDs (CGM eMDs) through its secure CGM APIs. This allows programmatic extraction of necessary clinical and administrative data, such as patient demographics, diagnosis codes, procedure codes, and supporting clinical documentation, directly from the EMR. This method ensures data accuracy and eliminates manual data entry, supporting efficient X12 278 submissions.
Can Klivira handle X12 278 transactions through Change Healthcare Clearinghouse?
Yes, Klivira is designed to automate the submission of HIPAA X12 278 prior authorization requests. We leverage the Change Healthcare Clearinghouse for electronic transmission to payers that support this standard, ensuring compliant and efficient communication of authorization needs. Klivira also supports direct payer integrations and other ePA standards like NCPDP SCRIPT where applicable.
What specific eMDs modules or screens are involved in the Klivira integration?
The Klivira integration primarily operates in the background, pulling data from various points within eMDs where patient, encounter, and order information resides. While users will continue to initiate orders or schedule services within their usual eMDs Solution Series, Lytec, or Medisoft screens, Klivira's automation surface leverages the underlying CGM APIs to gather the necessary data for PA submission without requiring specific module interaction beyond the initial clinical documentation.
How does Klivira provide status updates back to eMDs users?
Klivira actively monitors the status of submitted prior authorizations, whether through X12 278 responses from Change Healthcare, direct payer portal updates, or other ePA channels. Once a status change or approval is received, Klivira pushes this updated information, including decision letters and authorization numbers, directly back into the eMDs system, providing real-time visibility to prior authorization coordinators and billing staff within their familiar EMR interface.
Is this integration suitable for all eMDs users, including those on older versions like Lytec or Medisoft?
Klivira's integration capability relies on the availability and accessibility of eMDs' CGM APIs. While we aim for broad compatibility, the specific version of eMDs (including Solution Series, Lytec, or Medisoft) in use will determine the exact integration points and data access capabilities. We recommend a discovery call to assess your specific eMDs environment and ensure seamless integration.
Related coverage
Other emds prior auth coverage
- eMDs Aetna Prior Authorization Automation: Connecting Ambulatory Workflows to Aetna's Channels
- Streamlining eMDs Anthem (Elevance Health) Prior Authorization Automation
- Achieve eMDs Anthem Blue Cross California Prior Authorization Automation
- Optimize eMDs Blue Shield of California Prior Authorization Automation
- eMDs Florida Blue Prior Authorization Automation for Ambulatory Practices
- eMDs BCBS Texas Prior Authorization Automation: Optimize Ambulatory Workflows
- Accelerate eMDs Medi-Cal Prior Authorization Automation
- Accelerating eMDs Centene Prior Authorization Automation
- eMDs Cigna Prior Authorization Automation: Optimizing Ambulatory Workflows
- Streamlining eMDs Humana Prior Authorization Automation
- Streamlining eMDs Kaiser Permanente Prior Authorization Automation
- Enhance eMDs Medicaid Prior Authorization Automation for Ambulatory Care
- eMDs Medicare Prior Authorization Automation
- Streamlining eMDs Molina Healthcare Prior Authorization Automation
- Accelerating eMDs TRICARE Prior Authorization Automation
- Streamlining eMDs UnitedHealthcare Prior Authorization Automation
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