MatrixCare BCBS New York Prior Authorization Automation

Klivira delivers robust MatrixCare BCBS New York prior authorization automation, bridging the gap between your long-term care EMR and BlueCross BlueShield of New York's diverse submission channels.

For revenue cycle directors and prior authorization coordinators utilizing MatrixCare in long-term care, home health, and hospice settings, navigating the specific requirements of BCBS New York plans presents a significant administrative burden. Manual processes for medical and pharmacy PAs can delay care and impact revenue, particularly when dealing with multiple submission portals and varied policy sets.

The Challenge of MatrixCare Prior Authorizations for BCBS New York

Providers leveraging MatrixCare for long-term and post-acute care frequently encounter complex prior authorization workflows for services covered by BCBS New York plans, including Excellus and Highmark NY. Submitting medical PAs often requires navigating Availity Essentials, while specific services like advanced imaging or cardiology may route through Carelon Medical Benefits Management. Pharmacy PAs, meanwhile, are typically managed through CarelonRx, each demanding distinct processes that divert staff time from patient care.

Klivira's Integration with MatrixCare via APIs

Klivira integrates directly with MatrixCare through its robust APIs, enabling seamless data exchange for prior authorization requests. This direct connection extracts necessary patient demographics, clinical documentation, and service codes directly from the MatrixCare EHR, eliminating manual data entry and reducing the risk of errors. Our platform acts as an intelligent layer, orchestrating the submission process without disrupting your established EMR workflows.

Streamlining BCBS New York Submission Channels

Our platform centralizes prior authorization submissions to BCBS New York plans. For medical PAs, Klivira supports submissions through Availity Essentials and facilitates routing to Carelon Medical Benefits Management for services such as advanced imaging, cardiology, and sleep studies. Pharmacy PAs are routed to CarelonRx. Klivira also supports X12 278 transactions via clearinghouses, ensuring comprehensive coverage across all required channels, including New York Medicaid managed care.

Automating Prior Authorization for Long-Term and Post-Acute Care Services

Klivira automates prior authorization for common services and therapies critical to long-term and post-acute care, including advanced imaging, durable medical equipment, and certain specialty medications. The platform intelligently applies BCBS New York's medical policies, which are published through Empire's provider site and align with the Elevance corporate UM framework, with specific New York variations. This ensures requests are submitted with the correct clinical documentation from the outset.

Compliance and Turnaround Time Considerations

Klivira's automation platform is designed to align with New York insurance regulations governing commercial PA timeframes, as well as New York state Medicaid managed-care contracts. For Medicare Advantage plans, we factor in the requirements of CMS-0057-F. This helps organizations maintain compliance and optimize for faster turnaround times, reducing administrative burden and improving patient access to necessary care.

Key Benefits of Klivira for MatrixCare & BCBS NY PA

Automated data extraction from MatrixCare via APIs.
Centralized submission to Availity, Carelon MBM, and CarelonRx for BCBS NY.
Reduced manual effort and administrative overhead.
Improved compliance with state and federal PA regulations.
Faster prior authorization approvals for long-term care services.
Enhanced visibility into PA status across all BCBS NY plans.

Frequently asked questions

How does Klivira integrate with MatrixCare for prior authorizations?

Klivira integrates directly with MatrixCare using its published APIs. This allows our platform to securely extract necessary patient demographics, clinical notes, and order details directly from the EMR, automating the creation of prior authorization requests and eliminating manual data entry.

Which BCBS New York plans does Klivira support for prior authorizations?

Klivira supports prior authorization submissions for various BCBS New York plans, including Excellus BlueCross BlueShield and Highmark Blue Cross Blue Shield of Western New York (often referred to collectively as BCBS NY). Our system is configured to handle the specific submission channels and policy requirements for these plans.

Does Klivira handle Carelon Medical Benefits Management submissions for BCBS NY?

Yes, Klivira is designed to facilitate submissions to Carelon Medical Benefits Management (formerly AIM Specialty Health) for services requiring their review, such as advanced imaging, cardiology, and sleep studies, as mandated by BCBS New York. Our platform intelligently routes these specific requests to the appropriate Carelon MBM portal.

How does Klivira address pharmacy PAs with CarelonRx for BCBS NY?

For pharmacy prior authorizations with BCBS New York, which are typically managed through CarelonRx (formerly IngenioRx), Klivira streamlines the submission process. Our system ensures that all necessary clinical documentation is included and routed correctly to CarelonRx, accelerating the approval process for prescribed medications.

What are the benefits of automating PA for long-term care providers using MatrixCare?

Automating prior authorizations for long-term care providers using MatrixCare significantly reduces administrative burden, minimizes denial rates, and improves turnaround times. This allows staff to focus more on patient care, enhances revenue cycle efficiency, and ensures timely access to necessary services and medications for residents.