ModMed SCAN Health Plan Prior Authorization Automation

Navigating Prior Authorizations from ModMed to SCAN Health Plan

ModMed's specialty-specific EHRs (EMA Dermatology, EMA Ophthalmology, etc.) generate rich clinical data tailored to each practice's focus. However, extracting this data and submitting it to SCAN Health Plan, a prominent Medicare Advantage insurer, often involves disparate manual processes. This complexity is compounded by SCAN's focus on senior care, where specific medical necessity criteria and documentation requirements for specialty procedures or medications are common, necessitating precise data submission across various payer channels.

Klivira's Deep Integration with ModMed's Specialty EHRs

Klivira leverages ModMed's robust integration surfaces, including its FHIR R4 read APIs and SMART App Launch capabilities, to embed directly within the ModMed clinical UI. This allows for secure, real-time extraction of patient data, including diagnoses, procedures, medications, and clinical notes, directly from ModMed's specialty-tuned templates. Our solution is designed to adapt to the distinct clinical content and workflow integration points across ModMed's different specialty product lines, such as EMA Dermatology or EMA Ophthalmology.

Automating Specialty-Specific Prior Authorizations for SCAN Health Plan Members

Given ModMed's focus on specialties like dermatology, ophthalmology, gastroenterology, and orthopedics, Klivira targets high-volume, complex prior authorizations common for SCAN Health Plan's Medicare Advantage beneficiaries. This includes automating PAs for specialty biologics (e.g., for psoriasis or IBD), advanced imaging (e.g., MRI/CT for orthopedic conditions), and specific surgical procedures. Our system intelligently identifies the necessary clinical documentation from ModMed's patient chart and procedure documentation sections to meet SCAN's medical necessity criteria.

Optimizing Data Flow and Submission to SCAN Health Plan

Klivira automates the assembly of comprehensive PA requests, utilizing the detailed clinical information extracted from ModMed. We then facilitate submission to SCAN Health Plan through the most efficient available channels, including secure ePA platforms or direct payer portals. This ensures that all required data, from clinical notes to pathology integration details, is accurately and promptly transmitted, minimizing the potential for denials due to incomplete or incorrect submissions, a common challenge with X12 278 transactions if not properly managed.

Tangible Benefits for ModMed Practices

• Reduced manual effort for prior authorization coordinators, freeing up staff for patient care.
• Accelerated turnaround times for SCAN Health Plan approvals, improving patient access to care.
• Lower denial rates through accurate, complete, and timely submission of clinical documentation from ModMed.
• Enhanced operational efficiency across revenue cycle management for Medicare Advantage cases.
• Improved staff satisfaction by eliminating repetitive, high-stress administrative tasks.

Compliance and Data Security Considerations

Klivira operates with a commitment to secure handling of PHI, adhering to HIPAA regulations. Our integration with ModMed's FHIR endpoints ensures data exchange occurs over secure, encrypted channels. Organizations should always discuss specific data sharing agreements and workflows with their compliance teams to ensure alignment with internal policies and regulatory requirements.