Epic New York Medicaid Prior Authorization Automation

The Challenge of Epic New York Medicaid Prior Authorization Workflows

For large health systems and academic medical centers using Epic, prior authorization for New York Medicaid often involves significant context switching out of Hyperspace or Hyperdrive. Manual fax workflows and fragmented access to various payer portals disrupt clinician workflow, leading to delays and increased administrative costs. Managing denial appeals for Medicaid services further complicates the revenue cycle.

Navigating New York Medicaid Prior Authorization Requirements

As the New York state Medicaid program, NY Medicaid operates with multiple Managed Care Organization (MCO) contracts, each potentially having distinct prior authorization requirements and submission channels. While some payers support X12 278 transactions or ePA solutions, many still require submissions through proprietary web portals or fax. Klivira's platform is engineered to connect to these diverse channels, centralizing the submission process.

Klivira's SMART on FHIR Integration with Epic

Klivira integrates with Epic using industry-standard mechanisms like SMART on FHIR and CDS Hooks, allowing for a seamless prior authorization experience within Hyperspace or Hyperdrive. Our solution can launch directly from the patient chart, leveraging FHIR R4 read APIs to pull relevant clinical data (e.g., Coverage, ServiceRequest, DocumentReference, Condition) and pre-populate authorization requests. This eliminates manual data extraction and reduces errors at the point of order entry.

Key Integration Capabilities for Epic & New York Medicaid Workflows

• **EHR-Launch from Hyperspace/Hyperdrive**: Initiate PA workflows directly from Epic with patient and encounter context via SMART App Launch.
• **CDS Hooks for PA Detection**: Surface coverage requirements and initiate PA workflows at the point of order entry (e.g., order-select, order-sign hooks).
• **FHIR DocumentReference Write-Back**: Deposit completed PA packets, approval letters, and supporting documentation directly into Epic's Chart Review and Media sections.
• **Automated Data Aggregation**: Utilize FHIR R4 read capabilities for US Core resources and Bulk FHIR (`Patient/$everything`) to compile comprehensive clinical histories for NY Medicaid submissions.
• **Inbasket Task Routing**: Route PA status updates, requests for additional information, and peer-to-peer review notifications to the responsible clinician or PA coordinator within Epic's Inbasket module.
• **USCDI Conformance**: Adhere to USCDI standards for data exchange, ensuring compatibility with Epic's ONC-certified products.

Automating Prior Authorization for New York Medicaid

Klivira's platform automates the submission of prior authorizations to New York Medicaid and its contracted MCOs, regardless of their preferred intake channel. By leveraging data directly from Epic, we minimize the need for manual data entry into payer portals. This automation accelerates turnaround times, reduces the incidence of preventable denials, and allows PA coordinators to focus on complex cases rather than repetitive tasks.

Enhancing Prior Authorization for Specific Service Lines

From high-cost specialty medications to advanced imaging and surgical procedures, many service lines require prior authorization from New York Medicaid. Klivira's integration with Epic ensures that the necessary clinical documentation is accurately assembled and submitted, supporting a wide range of medical services. This comprehensive approach helps ensure that patients receive timely access to medically necessary care.