Greenway Health Aetna Prior Authorization Automation

Klivira automates Greenway Health Aetna prior authorization workflows, reducing administrative burden and accelerating time to care for ambulatory practices.

Revenue cycle leaders and prior authorization coordinators at Greenway Health-powered ambulatory practices (including Intergy and Prime Suite users) face unique challenges navigating Aetna's diverse prior authorization requirements. Manual processes, portal-hopping, and policy lookups consume valuable staff time, delaying patient access to necessary services. Klivira provides a purpose-built solution to streamline these critical operational demands.

Navigating Aetna Prior Authorization from Greenway Health

Aetna, a CVS Health company, administers prior authorizations through multiple channels depending on the benefit category. For Greenway Health users, this often means navigating the Availity provider portal for medical benefit requests, managing X12 278 transactions via clearinghouses, and utilizing ePA partners like CoverMyMeds or Surescripts for pharmacy benefits. Klivira integrates directly with your Greenway Health EMR to centralize and automate these disparate workflows.

Seamless Integration with Greenway Health EMRs

Klivira connects with your Greenway Health EMR (Intergy or Prime Suite) through the Greenway Marketplace. This integration enables direct extraction of patient demographics, clinical notes, and order details, pre-populating prior authorization requests and minimizing manual data entry. By embedding automation into your existing EMR environment, Klivira reduces staff training overhead and promotes a more efficient, compliant workflow for Aetna submissions.

Aetna Prior Authorization Submission Channels Supported

Medical Benefit PA via Availity portal for commercial and Medicare Advantage plans.
X12 278 electronic submissions for eligible medical procedures and inpatient admission notifications.
Pharmacy Benefit PA through CoverMyMeds and Surescripts ePA for outpatient retail prescriptions.
CVS Caremark's direct provider portal for mail-order pharmacy and case-managed scenarios.

Accelerating Medical and Pharmacy Benefit PA for Aetna

Klivira's platform is engineered to handle the nuances of both medical and pharmacy benefit prior authorizations for Aetna members. Whether it's a medical procedure, advanced imaging, specialty biologic, or a retail prescription, our system routes requests through the appropriate Aetna channel. We help ensure that critical information, such as step-therapy adherence or medical necessity criteria from Aetna's Clinical Policy Bulletins (CPBs), is accurately captured and submitted.

Operationalizing Aetna Clinical Policy Bulletins (CPBs)

Aetna's medical necessity criteria are published as Clinical Policy Bulletins (CPBs) in their public library. Klivira assists your team in interpreting and applying these versioned, dated policies, including those that reference external criteria from sources like MCG or NCCN. This ensures that submitted documentation aligns with Aetna's requirements for procedures, advanced diagnostics, and specialty medications like GLP-1s or other biologics, reducing the likelihood of denials.

Compliance and Turnaround Time Considerations

Klivira helps track prior authorization requests against Aetna's expected turnaround times, which are influenced by state-mandated minimums and NCQA Utilization Management accreditation standards. For Aetna's Medicare Advantage, Medicaid managed-care (Aetna Better Health), CHIP managed-care, and QHP-on-FFM lines of business, Klivira supports compliance with CMS-0057-F requirements for electronic prior authorization and decision timeframes, which phases in by 2027. It is important to note that Aetna's commercial line of business is not directly impacted by CMS-0057-F.

Frequently asked questions

How does Klivira integrate with Greenway Health EMRs for Aetna prior authorizations?

Klivira integrates with Greenway Health EMRs, including Intergy and Prime Suite, through the Greenway Marketplace. This allows for seamless data extraction from patient charts, pre-populating Aetna prior authorization requests directly from your EMR.

What Aetna prior authorization types can Klivira automate for Greenway Health users?

Klivira automates a wide range of Aetna prior authorization types, including medical benefit requests (e.g., procedures, imaging, specialty drugs under the medical benefit) and pharmacy benefit requests (e.g., retail and mail-order prescriptions) by routing them through Aetna's specified channels.

Does Klivira support submissions to Aetna's Availity portal?

Yes, Klivira automates interactions with Aetna's primary multi-payer provider workspace, the Availity portal, for medical benefit precertification requests. This streamlines the submission process for Greenway Health users, reducing manual portal navigation.

How does Klivira handle Aetna's Clinical Policy Bulletins (CPBs) and medical necessity criteria?

Klivira assists in applying Aetna's Clinical Policy Bulletins (CPBs) by helping ensure that submitted documentation aligns with the specific medical necessity criteria outlined in these policies. This includes criteria for step therapy and those referencing external sources like MCG or NCCN.

Is CMS-0057-F relevant for Aetna commercial plans?

No, CMS-0057-F directly impacts Aetna's Medicare Advantage, Medicaid managed-care, CHIP managed-care, and Qualified Health Plans on the Federal Facilitated Marketplace. Aetna's commercial line of business is not directly impacted by the rule's requirements.