Epic Aetna Prior Authorization Automation: Accelerating Approvals

Klivira delivers robust Epic Aetna prior authorization automation, directly integrating with your Epic EMR to streamline the complex process of securing Aetna approvals.

For large health systems and academic medical centers utilizing Epic Systems, managing prior authorizations for Aetna members presents significant operational challenges. Manual fax workflows, constant context switching out of Hyperspace, and fragmented access to Aetna's various submission channels lead to delays, increased denials, and staff burnout. Klivira addresses these pain points by embedding automation directly into your Epic environment.

Navigating Aetna Prior Authorizations from Epic

Organizations leveraging Epic Systems often face a disjointed process for Aetna prior authorizations. Medical benefit requests typically route through the Availity provider portal, while pharmacy benefit PAs, administered by CVS Caremark, utilize ePA partners like CoverMyMeds or Surescripts. This multi-channel approach, combined with the need to extract clinical documentation from Epic's Chart Review or Media tabs, creates substantial administrative overhead for prior authorization coordinators.

Seamless Integration with Epic via SMART on FHIR

Klivira integrates with Epic using industry-standard mechanisms like SMART on FHIR, enabling EHR-launched workflows directly from Hyperspace or Hyperdrive. We leverage FHIR R4 read capabilities for essential clinical data, including ServiceRequest, MedicationRequest, and DocumentReference, to compile comprehensive PA packets. Our platform also supports FHIR R4 write-back for critical artifacts such as DocumentReference (for deposited PA packets), ServiceRequest (for authorization numbers), Communication, and Task, ensuring PA status and decisions are visible within Epic's Inbasket and Chart Review.

Automating Aetna's Diverse Submission Channels

Klivira automates submissions across Aetna's primary channels. For medical benefit prior authorizations, we facilitate electronic submission via X12 278 transactions or through the Availity portal. For pharmacy benefit PAs, our system integrates with Aetna's ePA partners, CoverMyMeds and Surescripts, ensuring compliance with NCPDP SCRIPT standards. This unified approach eliminates manual data entry and reduces the need for staff to navigate multiple payer portals.

Precision with Aetna Clinical Policy Bulletins (CPBs)

Aetna's medical necessity criteria are published in their Clinical Policy Bulletins (CPBs), which are critical for successful prior authorization. Klivira's automation engine incorporates these CPBs, ensuring that prior authorization requests are accurately compiled with the required clinical documentation and meet specific criteria for procedures, advanced imaging, or specialty medications. This proactive validation minimizes denials related to insufficient documentation or non-compliance with step therapy protocols.

Compliance and Turnaround Times for Aetna PAs

Klivira supports compliance with Aetna's turnaround timeframes, which are governed by state regulations and NCQA UM accreditation standards. For Aetna's Medicare Advantage lines of business, Klivira helps organizations align with the requirements of CMS-0057-F, which mandates 72-hour standard and 24-hour expedited decision windows. Our platform assists in tracking and managing these deadlines, reducing the risk of administrative denials and ensuring timely patient access to care.

Frequently asked questions

How does Klivira integrate with Epic for Aetna prior authorizations?

Klivira integrates with Epic via SMART on FHIR, enabling EHR-launched workflows from Hyperspace or Hyperdrive. This allows for direct access to patient context and clinical documentation within Epic, while also supporting write-back of PA status, authorization numbers, and completed PA packets as DocumentReferences.

Can Klivira automate pharmacy benefit prior authorizations for Aetna (CVS Caremark)?

Yes, Klivira automates pharmacy benefit prior authorizations for Aetna members by integrating with Aetna's ePA partners, CoverMyMeds and Surescripts. This ensures that pharmacy PA requests, administered by CVS Caremark, are submitted electronically and in compliance with NCPDP SCRIPT standards.

How does Klivira help with Aetna PA denials within the Epic workflow?

Klivira assists in reducing Aetna PA denials by ensuring that submissions align with Aetna's Clinical Policy Bulletins (CPBs) and required documentation. If a denial occurs, our platform helps manage the appeals workflow, allowing for efficient submission of additional information and tracking of peer-to-peer review requests, with updates visible in Epic's Inbasket.

Does Klivira support Aetna's X12 278 transactions for medical PAs?

Yes, Klivira supports the submission of medical benefit prior authorizations to Aetna via X12 278 transactions through clearinghouses. This capability is crucial for organizations seeking to standardize and automate their electronic prior authorization processes for Aetna's commercial and Medicare Advantage lines of business.

What Epic modules does Klivira interact with for Aetna prior authorizations?

Klivira interacts with several Epic modules relevant to prior authorizations, including Chart Review (for clinical documentation), Orders activity (for triggering PA requirements via CDS Hooks), Media (for attaching PA packets), and Inbasket (for task routing and status updates). This ensures a comprehensive and integrated PA workflow within your Epic environment.