NextGen Healthcare Bright HealthCare Prior Authorization Automation

The Challenge of Bright HealthCare PAs from NextGen Healthcare

Specialty ambulatory groups using NextGen Healthcare frequently encounter bottlenecks when submitting prior authorizations to Bright HealthCare, particularly for their Medicare Advantage beneficiaries. The typical workflow involves staff manually compiling clinical documentation from NextGen's Patient Chart and Documents section, then transcribing or uploading this information to Bright HealthCare's designated submission channels, which may include their payer portal or X12 278 transactions. This fragmented process is prone to errors and consumes valuable staff time.

Seamless Integration with NextGen Healthcare for PA Automation

Klivira integrates directly with NextGen Healthcare, leveraging its modern interoperability capabilities to streamline prior authorization workflows. Our platform utilizes NextGen's FHIR R4 endpoints, including US Core resources, to securely access PA-relevant clinical and administrative data such as Patient, Encounter, Coverage, ServiceRequest, MedicationRequest, DocumentReference, Practitioner, and Condition. Through SMART App Launch, Klivira can be embedded within the NextGen clinical UI, providing patient and encounter context at the point of care, and can write back PA statuses and artifacts to the NextGen Patient Chart, Documents, Orders activity, and Tasks/Worklists via the NextGen API.

Optimizing Prior Authorizations for Bright HealthCare Medicare Advantage

Bright HealthCare's focus on Medicare Advantage plans means specific prior authorization requirements for specialty drugs, advanced imaging, and complex procedures are common. Klivira's platform is designed to navigate these complexities by automating submissions to Bright HealthCare's various channels, including payer portals and X12 278 electronic prior authorization (ePA) transactions. This ensures that authorizations for high-cost medications like biologics or GLP-1s, or critical imaging studies, are processed efficiently and accurately, aligning with Bright HealthCare's specific policy guidelines.

Key Prior Authorization Workflows for NextGen + Bright HealthCare

Our integration specifically targets high-volume and high-impact prior authorization workflows critical for NextGen users serving Bright HealthCare members. This includes automated submission for specialty drug ePA, ensuring correct documentation for biologics or other injectables. We also streamline advanced imaging authorizations, routing requests through appropriate benefit management programs, and facilitate surgical procedure PAs. By extracting and formatting necessary clinical data from NextGen, Klivira ensures that Bright HealthCare receives comprehensive and compliant submissions, reducing the likelihood of denials and appeals.

Klivira's Architectural Approach with NextGen

Klivira's integration architecture with NextGen Healthcare is built for reliability and scalability, accommodating both cloud-hosted and on-premise NextGen deployments. We leverage NextGen Connect (Mirth) for robust data exchange where applicable, alongside direct FHIR R4 API integration. This dual approach ensures comprehensive access to the clinical data required for prior authorization, while also enabling seamless write-back of PA status updates and approved authorizations directly into the NextGen patient record, maintaining a single source of truth for clinical and administrative staff.

Benefits of Klivira for NextGen Healthcare and Bright HealthCare

• Automated data extraction from NextGen, reducing manual entry for Bright HealthCare submissions.
• Accelerated turnaround times for Bright HealthCare Medicare Advantage prior authorizations.
• Improved accuracy of PA submissions, minimizing denials and appeals.
• Enhanced staff efficiency, allowing PA coordinators to focus on complex cases.
• Real-time status tracking for Bright HealthCare PAs directly within NextGen workflows.
• Consistent application of Bright HealthCare's specific medical policies.