NextGen Healthcare Centene Prior Authorization Automation

The Intersection of NextGen Healthcare and Centene Prior Authorizations

Specialty ambulatory groups utilizing NextGen Healthcare often face the challenge of managing prior authorizations for Centene's federated structure. This involves interacting with state-specific subsidiaries like Fidelis Care, Health Net, or Superior HealthPlan, as well as national brands such as Ambetter (ACA marketplace) and Wellcare (Medicare). Each entity typically requires submissions through its own provider portal or specific X12 278 channels, creating a fragmented workflow for NextGen users.

Klivira's Integration with NextGen Healthcare

Klivira integrates directly with NextGen Healthcare using its FHIR R4 endpoints and SMART App Launch capabilities. This allows our platform to securely access relevant clinical and administrative data, including patient demographics, encounters, coverage, and service requests, directly from the NextGen Patient Chart. By leveraging NextGen's API, Klivira streamlines the data extraction necessary for prior authorization submission, reducing manual data entry and ensuring data accuracy.

Navigating Centene's Diverse Prior Authorization Channels

• **Medical PA:** Klivira automates submissions to Centene's subsidiary-specific provider portals and supports X12 278 transactions via clearinghouses, abstracting the variance across plans like Buckeye Health Plan or Sunshine Health.
• **Pharmacy PA:** We facilitate electronic prior authorization (ePA) for pharmacy benefits through Envolve Pharmacy Solutions and industry partners like CoverMyMeds and Surescripts, covering retail and some specialty medications.
• **Behavioral Health PA:** Klivira helps manage prior authorization requirements for behavioral health services, which are often handled under Centene Behavioral Health, aligning with subsidiary-specific carve-out or in-network guidelines.
• **Ambetter & Wellcare:** Submissions for Ambetter (ACA marketplace) and Wellcare (Medicare) plans are automated through the respective state subsidiary portals, adhering to their specific PA criteria and formularies.
• **Inpatient Admission Notification:** Our platform supports the timely submission of concurrent review intake and inpatient admission notifications, respecting the varied state Medicaid contract timeframes and Medicare Advantage rules.

Automating Key Workflows for Specialty Ambulatory Practices

For NextGen users in specialty ambulatory settings, Klivira focuses on automating high-volume and complex prior authorization workflows. This includes managing medical necessity reviews for outpatient procedures, advanced imaging, and specialty drug therapies on the medical benefit. By integrating with NextGen's Orders activity and Documents sections, Klivira ensures that all required clinical documentation is accurately compiled and submitted, aligning with Centene's utilization management policies that often leverage InterQual or NCCN criteria.

Ensuring Compliance and Efficiency with Centene Policies

Klivira assists practices in adhering to Centene's complex policy landscape, which includes subsidiary-specific clinical policies and the layering of state Medicaid agency rules for Medicaid managed care lines. Our automation aims to support compliance with turnaround timeframes, including those mandated by state Medicaid agencies and the statutory timeframes for Medicare Advantage plans, which are broadly impacted by CMS-0057-F requirements. By integrating PA status updates into NextGen's Tasks/Worklists, Klivira helps optimize follow-up and appeals processes.