Greenway Health Highmark Prior Authorization Automation

Klivira delivers comprehensive Greenway Health Highmark prior authorization automation, directly addressing the complexities faced by ambulatory practices utilizing Intergy and Prime Suite.

For revenue cycle directors and prior authorization coordinators managing Greenway Health EMRs, navigating Highmark's diverse prior authorization requirements across multiple states presents a significant operational burden. From medical benefit PAs via Availity to specialty vendor routing and pharmacy benefit considerations, manual workflows consume valuable staff time and delay patient care. Klivira streamlines this process, ensuring efficiency and compliance.

Navigating Highmark Prior Authorizations from Greenway Health

Ambulatory practices using Greenway Health's Intergy or Prime Suite often encounter a fragmented process when submitting prior authorizations to Highmark. Highmark routes most commercial and Medicare Advantage medical-benefit PA submissions through Availity Essentials, while also accepting X12 278 transactions via clearinghouses for impacted procedures. This dual-channel requirement, coupled with state-specific operational variances across Pennsylvania, West Virginia, Delaware, and New York, demands a robust automation solution.

Seamless Integration with Greenway Health EMRs

Klivira integrates directly with your Greenway Health environment, supporting both Intergy and Prime Suite, to embed prior authorization workflows within your existing clinical and administrative operations. Our solution is available through the Greenway Marketplace, ensuring a validated and secure connection that minimizes disruption and accelerates adoption for your ambulatory practice.

Highmark's Diverse Submission Channels Automated

Klivira provides comprehensive support for Highmark's varied prior authorization submission channels. We automate the submission of medical-benefit PAs to Availity Essentials and facilitate X12 278 transactions where applicable. For specific clinical domains such as advanced imaging, cardiology, musculoskeletal, and radiation oncology, Klivira manages routing to Highmark's designated specialty benefit-management vendors, ensuring each request reaches the correct destination.

Leveraging Highmark Utilization Management Policies

Highmark publishes extensive medical policy and clinical utilization management guideline libraries through its provider site. Klivira's platform incorporates these guidelines, helping to ensure that prior authorization requests submitted from Greenway Health align with Highmark's current criteria. This proactive approach helps reduce initial denials and streamlines the review process.

Compliance with CMS-0057-F for Highmark Plans

For Highmark's Medicare Advantage, Medicaid managed-care, and Qualified Health Plan (QHP) lines on the Federal Facilitated Marketplace, the CMS-0057-F rule introduces new requirements for electronic prior authorization. Klivira's automation capabilities are designed to help your organization meet these evolving federal mandates, facilitating faster turnaround times and improved transparency for impacted Highmark plans.

Key Prior Authorization Workflows for Greenway Health + Highmark

Automated submission of medical PAs to Availity Essentials for commercial and Medicare Advantage plans.
Management of X12 278 transactions for eligible procedures.
Routing of advanced imaging, cardiology, MSK, and radiation oncology PAs to Highmark's specialty vendors.
Streamlined pharmacy PA processes, with PBM verification for accurate routing.
Real-time status updates for prior authorizations initiated from Intergy or Prime Suite.

Frequently asked questions

How does Klivira integrate with Greenway Health EMRs like Intergy and Prime Suite?

Klivira integrates seamlessly with Greenway Health's Intergy and Prime Suite EMRs through the Greenway Marketplace. This integration allows prior authorization workflows to be initiated directly from the EMR, leveraging patient data to pre-populate forms and streamline the submission process without requiring staff to leave their native system.

Which Highmark prior authorization channels does Klivira support?

Klivira supports Highmark's primary prior authorization channels, including medical-benefit submissions via Availity Essentials and X12 278 transactions. Additionally, we facilitate routing to specific specialty benefit-management vendors used by Highmark for domains such as advanced imaging, cardiology, and radiation oncology. Pharmacy benefit manager (PBM) routing is also supported, with verification for specific plans.

How does Klivira handle Highmark's state-specific PA rules?

Highmark operates across multiple states, including PA, WV, DE, and NY, each with unique insurance regulations and PA timeframe rules. Klivira's platform is designed to adapt to these state-specific nuances, helping ensure that submissions from Greenway Health EMRs adhere to the correct regulatory requirements and turnaround norms.

Does Klivira help with Highmark's utilization management policy adherence?

Yes, Klivira helps your team adhere to Highmark's utilization management policies. Our system is designed to leverage Highmark's published medical policies and clinical guidelines, assisting in the construction of prior authorization requests that align with payer criteria, thereby improving the likelihood of approval.

Is Klivira compliant with new CMS ePA mandates for Highmark plans?

Klivira's platform is designed with an understanding of evolving regulatory landscapes, including the requirements of CMS-0057-F which impacts Highmark's Medicare Advantage, Medicaid managed-care, and QHP lines. Our automation capabilities support the electronic exchange of prior authorization information to help your organization meet these federal mandates.