Streamlining NextGen Healthcare Highmark Prior Authorization Automation

For specialty ambulatory groups utilizing NextGen Healthcare, achieving efficient prior authorization for Highmark plans across Pennsylvania, West Virginia, Delaware, and New York demands robust automation. Klivira delivers seamless NextGen Healthcare Highmark prior authorization automation.

The operational burden of prior authorization can significantly impact revenue cycles and patient access, particularly for mid-sized specialty practices using NextGen Healthcare. Manually navigating Highmark's diverse submission channels from within the EMR workflow consumes valuable staff time and introduces potential for delays.

The NextGen Healthcare to Highmark Prior Authorization Challenge

NextGen Healthcare is a prominent EMR for specialty ambulatory groups, requiring frequent prior authorizations for various services and medications. Submitting these PAs to Highmark, which covers members across Pennsylvania, West Virginia, Delaware, and New York, often involves navigating multiple payer portals or manual processes that disrupt clinical workflows and delay care.

Klivira's Integration with NextGen Healthcare

Klivira leverages NextGen Healthcare's robust integration surfaces, including its FHIR R4 endpoints and SMART App Launch capabilities. This allows Klivira to securely access critical clinical and administrative data (such as Patient, Encounter, Coverage, ServiceRequest, and MedicationRequest) directly from the NextGen EMR. Our platform can launch contextually from within the NextGen clinical UI, embedding automation into existing workflows and providing write-back for PA documentation into the Patient Chart or Documents section.

Navigating Highmark's Prior Authorization Channels

Highmark primarily routes medical-benefit prior authorization submissions through Availity Essentials for commercial and Medicare Advantage plans. Additionally, Highmark accepts X12 278 transactions via clearinghouses for impacted procedures. Klivira streamlines these processes by automating submissions to Availity and facilitating X12 278 transactions, significantly reducing the manual data entry and portal navigation required for NextGen users in Highmark's service areas.

Optimizing Specialty-Specific PA Workflows

Given NextGen's focus on specialty practices, common prior authorization needs include advanced imaging, biologics, and other specialty medications. Klivira integrates with NextGen's Orders activity and Documents sections to identify PA requirements early. Our platform connects to Highmark's utilization-management policy libraries, helping practices proactively address requirements for services like advanced imaging, cardiology, or musculoskeletal procedures, which may be routed through specialty benefit-management vendors.

Key Considerations for NextGen Healthcare + Highmark Workflows

Leveraging NextGen's FHIR R4 and SMART App Launch for seamless data exchange.
Automating submissions to Highmark's primary portal, Availity Essentials.
Facilitating X12 278 transactions for medical benefit prior authorizations.
Managing state-specific PA requirements across Highmark's service areas (PA, WV, DE, NY).
Integrating PA status and documentation into NextGen's Patient Chart and Tasks/Worklists.

Regulatory Alignment and Compliance for Highmark Submissions

Highmark's Medicare Advantage, Medicaid managed-care, and QHP-on-FFM lines are impacted by CMS-0057-F, which mandates electronic prior authorization and specific turnaround times. Klivira's platform is designed to align with these evolving federal requirements, as well as state-mandated minimums for PA turnaround times across Pennsylvania, West Virginia, Delaware, and New York, providing a consistent and compliant PA workflow for NextGen users.

Frequently asked questions

How does Klivira integrate with NextGen Healthcare for prior authorizations?

Klivira integrates with NextGen Healthcare by utilizing its FHIR R4 endpoints and SMART App Launch capabilities. This allows our platform to securely pull necessary patient and clinical data and launch contextually from within the NextGen EMR, streamlining the prior authorization submission process.

Which Highmark prior authorization channels does Klivira support?

Klivira supports Highmark's primary medical-benefit prior authorization channel, Availity Essentials, through automation. We also facilitate X12 278 transactions via clearinghouses for procedures where this is the accepted method, covering Highmark plans across PA, WV, DE, and NY.

Can Klivira help with specialty drug prior authorizations submitted from NextGen to Highmark?

Yes, Klivira is designed to streamline specialty drug prior authorizations. By integrating with NextGen's Orders activity and connecting to Highmark's utilization-management policies, we help ensure that the necessary documentation and forms for specialty medications are accurately prepared and submitted.

How does Klivira handle different state requirements for Highmark's service areas (PA, WV, DE, NY)?

Klivira helps practices navigate Highmark's state-specific requirements by providing a centralized platform that accounts for varying state-mandated minimums for PA turnaround times and other regulatory nuances across Pennsylvania, West Virginia, Delaware, and New York. This ensures submissions are compliant regardless of location.

Where do prior authorization artifacts appear in NextGen after using Klivira?

After using Klivira, prior authorization artifacts, such as submission confirmations and approval documents, can be written back into the NextGen EMR. These typically appear in the Patient Chart, Documents/Clinical Documents section, or are integrated with the Tasks/Worklists for follow-up.