Streamlining ModMed Highmark Prior Authorization Automation

The Challenge of Highmark Prior Authorizations from ModMed

ModMed (Modernizing Medicine), with its deep focus on specialties like dermatology, ophthalmology, orthopedics, gastroenterology, and plastic surgery, generates a high volume of complex prior authorizations. Highmark, a major payer across Pennsylvania, West Virginia, Delaware, and New York, routes most medical-benefit PA submissions through portals like Availity Essentials and accepts X12 278 transactions. The disconnect between ModMed's clinical workflows and Highmark's submission requirements often leads to manual data entry, fragmented communication, and delays in care.

Klivira's Integration with ModMed for Highmark Workflows

Klivira seamlessly integrates with ModMed's cloud-only EMR environment utilizing its FHIR R4 read APIs (covering US Core resources) and supporting SMART App Launch. This allows Klivira to pull relevant patient data, procedure codes, and clinical documentation directly from ModMed's specialty-tuned patient charts and procedure documentation. By embedding within the ModMed clinical UI, Klivira provides a contextual workflow that aligns with specialty-specific PA needs, whether for Mohs notes in EMA Dermatology or retinal imaging in EMA Ophthalmology.

Highmark Prior Authorization Channels Supported

• **Availity Essentials:** Klivira automates submissions to Highmark's primary medical PA portal, Availity Essentials, streamlining the process for commercial and Medicare Advantage plans.
• **X12 278 Transactions:** For procedures supporting electronic submission, Klivira facilitates X12 278 transactions via clearinghouses, ensuring compliance with industry standards.
• **Specialty Benefit Managers:** Klivira adapts to Highmark's routing for advanced imaging, cardiology, MSK, and radiation oncology through designated specialty benefit management vendors.
• **PBM Coordination (Pharmacy PA):** While Highmark's PBM relationships vary, Klivira's platform is designed to integrate with pharmacy benefit managers to support pharmacy prior authorizations where applicable.

Optimizing Specialty-Specific Prior Authorization Workflows

ModMed's distinct specialty product lines mean PA requirements and clinical content vary significantly. Klivira's platform is designed to handle these nuances, supporting high-volume PA profiles common in ModMed practices, such as biologics for dermatology or gastroenterology, or specialty injections in ophthalmology. By accessing Highmark's medical-policy and clinical-UM-guideline libraries, Klivira helps ensure submissions are aligned with current payer requirements, reducing the likelihood of denials.

Navigating Compliance and Turnaround Times for Highmark

Highmark's operations are subject to state-mandated minimums across PA, WV, DE, and NY, each with its own insurance regulator. Furthermore, Highmark's Medicare Advantage, Medicaid managed-care, and QHP-on-FFM lines are impacted payers under CMS-0057-F. Klivira’s automation helps practices meet these varying regulatory requirements and internal turnaround time goals, while providing a clear audit trail. Practices should discuss specific compliance considerations with their internal compliance teams.

Enhancing Efficiency for ModMed Users Submitting to Highmark

By automating the prior authorization process for ModMed practices dealing with Highmark, Klivira reduces manual effort, accelerates approval times, and improves staff utilization. This focused automation allows prior authorization coordinators to shift from administrative tasks to managing exceptions, ultimately improving patient access to necessary care and strengthening the practice's financial health.