Optimizing Epic Highmark Prior Authorization Automation

Klivira delivers comprehensive Epic Highmark prior authorization automation, integrating directly with your Epic EMR to streamline submissions to Highmark across Pennsylvania, West Virginia, Delaware, and New York.

Navigating prior authorizations for Highmark members from within an Epic environment often involves significant manual effort, context switching, and fragmented workflows. From order entry in Hyperspace to submission via Availity, the process can delay patient care and strain revenue cycle operations. Klivira addresses these challenges by consolidating and automating critical PA steps.

The Challenge: Manual Prior Authorizations Between Epic and Highmark

Health systems leveraging Epic EMRs frequently encounter bottlenecks when processing prior authorizations for Highmark members. Clinicians and PA coordinators often toggle between Epic Hyperspace or Hyperdrive and the Highmark provider portal, Availity Essentials, to gather clinical documentation, check policies, and submit requests. This manual process introduces delays, increases administrative overhead, and contributes to higher denial rates due to incomplete or untimely submissions.

Seamless Integration with Epic EMR Workflows

Klivira integrates with Epic using industry-standard interoperability mechanisms to embed prior authorization workflows directly into the clinician's native environment. Leveraging SMART on FHIR, Klivira launches from within Epic Hyperspace or Hyperdrive, providing patient and encounter context without requiring separate logins. This integration facilitates the aggregation of necessary clinical data from Chart Review, Orders activity, and Media, and supports write-back capabilities for critical PA artifacts.

Klivira's Epic Integration Capabilities

**SMART on FHIR Launch:** Initiate PA workflows directly from Hyperspace/Hyperdrive with contextual patient and encounter data.
**FHIR R4 Data Exchange:** Read clinical documentation (e.g., DocumentReference, ServiceRequest, MedicationRequest) and write back authorization details, status updates, and PA packets as DocumentReference or Communication resources.
**CDS Hooks Support:** Detect prior authorization requirements at the point of order entry (e.g., `order-select`, `order-sign`) using Da Vinci CRD-relevant hooks.
**Inbasket Integration:** Route PA status updates and task assignments to relevant Epic users via the Inbasket module.
**Showroom Pathway:** Klivira follows the Epic Showroom pathway for secure, validated application deployment within customer Epic instances.

Optimized Connectivity to Highmark Payer Channels

Klivira automates the submission of prior authorizations to Highmark by connecting directly to its primary channels. For medical benefit services, Klivira supports submissions through the Availity Essentials portal and via X12 278 transactions with clearinghouses. This ensures that requests for Highmark members in Pennsylvania, West Virginia, Delaware, and New York are routed efficiently and accurately, adhering to state-specific requirements.

Addressing Specific Highmark PA Use Cases

From advanced imaging to specialty medications and surgical procedures, Klivira's platform is designed to handle the diverse prior authorization requirements of Highmark. We automate the aggregation of supporting clinical documentation, cross-reference Highmark's utilization management policies, and manage submission and tracking. This includes support for lines of business impacted by CMS-0057-F, ensuring considerations for timely processing and data exchange for Highmark's Medicare Advantage and any QHP-on-FFM plans.

Enhanced Efficiency and Compliance

By automating the Epic Highmark prior authorization workflow, Klivira significantly reduces the administrative burden on PA teams. This frees up staff to focus on complex cases, improves turnaround times, and minimizes the risk of denials due to process inefficiencies. Our platform helps health systems maintain compliance with payer requirements and federal mandates like CMS-0057-F, ensuring a more streamlined and compliant prior authorization process for Highmark members.

Frequently asked questions

How does Klivira integrate with Epic for prior authorization submissions to Highmark?

Klivira integrates with Epic using SMART on FHIR, allowing our application to launch directly from Hyperspace or Hyperdrive. This enables contextual access to patient data, facilitating the collection of necessary clinical documentation for Highmark PA requests and supporting write-back of authorization statuses.

Which Highmark submission channels does Klivira support for prior authorizations?

For Highmark medical benefit prior authorizations, Klivira supports submissions through the Availity Essentials portal, which is Highmark's primary digital channel. We also facilitate X12 278 transactions via clearinghouses, ensuring comprehensive connectivity for your Highmark PA volume.

Can Klivira help with prior authorizations for specific service lines, such as specialty drugs or advanced imaging, for Highmark members?

Yes, Klivira is built to manage prior authorizations across various service lines, including specialty drugs, advanced imaging, and surgical procedures, for Highmark members. Our platform aggregates the specific clinical documentation required and aligns with Highmark's utilization management policies to streamline these complex requests.

How does Klivira ensure PA status updates are visible within Epic for Highmark authorizations?

Klivira utilizes Epic's FHIR write-back capabilities to deposit authorization numbers, status updates, and completed PA packets back into the patient's chart as DocumentReference or Communication resources. This ensures that relevant PA information is accessible to clinicians and staff within Epic's Chart Review and can be routed via Inbasket.

Does Klivira assist with compliance for Highmark plans impacted by CMS-0057-F?

Klivira's automation platform is designed to support the operational requirements driven by regulations such as CMS-0057-F. For Highmark's Medicare Advantage and any QHP-on-FFM plans, our system helps facilitate the timely exchange of PA data and adherence to processing timeframes, which are critical considerations for compliance with the rule.