Achieve Tebra Highmark Prior Authorization Automation

For independent practices utilizing Tebra, navigating Highmark's prior authorization requirements can be complex. Klivira delivers Tebra Highmark prior authorization automation, streamlining submissions and accelerating approvals.

Revenue cycle leaders and prior authorization coordinators in Tebra-powered practices face significant administrative burdens when managing Highmark PAs. This includes disparate submission channels, varying state-specific rules across Pennsylvania, West Virginia, Delaware, and New York, and the constant need to verify clinical policies. Klivira addresses these challenges by integrating directly with your Tebra environment.

The Challenge of Highmark Prior Authorizations from Tebra

Independent practices using Tebra often manage a high volume of Highmark prior authorization requests across multiple service lines. The manual process of extracting patient data from Tebra, logging into Availity Essentials, or preparing X12 278 transactions via clearinghouses introduces significant delays and potential for errors. This complexity is compounded by Highmark's diverse policy landscape and state-specific regulatory nuances.

Klivira's Integration with Tebra for Highmark Workflows

Klivira connects directly with your Tebra EHR through the Tebra API, enabling seamless data exchange for prior authorization requests. This integration minimizes manual data entry, ensuring that clinical documentation and patient demographics flow accurately from Tebra to Klivira's automation platform. Our system acts as an intelligent layer, orchestrating the PA process without disrupting your established Tebra workflows.

Navigating Highmark's Diverse Submission Channels

Highmark routes most medical-benefit prior authorizations through Availity Essentials for commercial and Medicare Advantage plans. Klivira automates the submission process to Availity, reducing the need for manual portal navigation. For procedures where X12 278 transactions are accepted, Klivira can prepare and route these through your existing clearinghouse connections, ensuring compliance with Highmark's preferred channels.

Addressing Specialty Benefit Management and Policy Access

Highmark, like many major payers, utilizes specialty benefit-management vendors for specific clinical domains such as advanced imaging, cardiology, musculoskeletal, and radiation oncology. Klivira integrates the intelligence to identify these cases and guide the submission through appropriate channels. Furthermore, Klivira centralizes access to Highmark's medical policies and clinical utilization management guidelines, ensuring submissions align with current requirements.

Key Benefits for Tebra Users Managing Highmark PAs

Automated data extraction from Tebra via API for PA forms.
Streamlined submission to Highmark's Availity Essentials portal.
Efficient routing of X12 278 transactions for applicable services.
Centralized access to Highmark medical policies and UM guidelines.
Reduced manual effort and administrative burden for PA coordinators.
Improved tracking and visibility into Highmark PA statuses.

Compliance Considerations for Highmark Prior Authorizations

Highmark's operations are subject to state-mandated minimum turnaround times across Pennsylvania, West Virginia, Delaware, and New York. Additionally, Highmark's Medicare Advantage, Medicaid managed-care, and Qualified Health Plan lines are impacted payers under CMS-0057-F, requiring adherence to new electronic prior authorization standards. Klivira helps practices meet these evolving compliance requirements by facilitating electronic submissions and providing audit trails.

Frequently asked questions

How does Klivira integrate with Tebra for Highmark prior authorizations?

Klivira integrates directly with your Tebra EHR using the Tebra API. This connection allows for automated extraction of patient demographics, clinical notes, and order details, which are then used to pre-populate prior authorization requests for Highmark. This eliminates manual data entry and ensures accuracy from your source system.

Which Highmark submission channels does Klivira support for Tebra users?

Klivira supports Highmark's primary submission channels. For medical-benefit prior authorizations, we automate submissions to Availity Essentials. For procedures where X12 278 transactions are accepted, Klivira facilitates their preparation and routing through your clearinghouse, ensuring comprehensive coverage for Highmark PA requirements.

Does Klivira help with Highmark's specialty benefit management vendors?

Yes, Klivira is designed to recognize and adapt to Highmark's use of specialty benefit-management vendors for specific clinical domains like advanced imaging or cardiology. Our platform helps identify when a submission needs to be routed through one of these vendors, guiding the PA coordinator through the correct process to ensure proper submission.

How does Klivira help Tebra practices stay compliant with Highmark PA rules?

Klivira helps Tebra practices stay compliant by providing up-to-date access to Highmark's medical policies and clinical guidelines. Our system also supports electronic submission processes that align with evolving regulations, including those outlined in CMS-0057-F for impacted Highmark plans, and helps track state-specific turnaround time requirements.

Can Klivira handle pharmacy prior authorizations for Highmark?

Klivira's platform is capable of handling pharmacy prior authorizations, including those for Highmark. While Highmark's specific PBM relationship requires verification, Klivira supports common ePA standards like NCPDP SCRIPT and can integrate with various PBM portals to streamline pharmacy benefit PA submissions.