PointClickCare Aetna Prior Authorization Automation for Long-Term Care

Klivira delivers robust PointClickCare Aetna prior authorization automation, specifically designed to streamline the complex PA workflows inherent in long-term care and senior living facilities.

Revenue cycle leaders and prior authorization coordinators at long-term care facilities using PointClickCare face unique challenges when securing approvals from Aetna. Manually navigating disparate payer portals and managing diverse medical and pharmacy benefit PA requirements can lead to delays, increased administrative burden, and potential revenue loss. Klivira addresses these pain points by integrating directly with your EMR and Aetna's submission channels.

The PointClickCare Aetna Prior Authorization Challenge in Senior Care

Long-term care facilities rely on PointClickCare for comprehensive resident management, yet prior authorization for Aetna members often remains a manual, fragmented process. This involves extracting resident data from PCC, then re-entering it into Aetna's various submission portals like Availity for medical benefits or CoverMyMeds/Surescripts for pharmacy benefits, creating a significant administrative overhead.

Seamless Data Exchange with PointClickCare APIs

Klivira integrates directly with PointClickCare via its robust APIs, enabling automated extraction of critical resident demographic, clinical, and encounter data. This eliminates the need for manual data entry into authorization requests, drastically reducing human error and improving the efficiency of initiating prior authorizations for Aetna members directly from your PointClickCare environment.

Aetna Payer Connectivity Across Diverse Benefit Categories

Medical Benefit PA via Availity portal
X12 278 electronic transactions for medical services
Pharmacy Benefit ePA via CoverMyMeds and Surescripts
Direct integration with CVS Caremark for mail-order pharmacy PA

Navigating Aetna's Clinical Policy Bulletins (CPBs)

Aetna's medical necessity criteria are detailed in its Clinical Policy Bulletins (CPBs), which are publicly available and versioned. Klivira's platform is designed to help prior authorization coordinators efficiently cross-reference these policies, ensuring submitted documentation aligns with the specific requirements for services common in long-term care, such as skilled nursing, rehabilitation, and specialty medications.

Accelerating Prior Authorization Turnaround Times

By automating data submission and intelligently routing requests, Klivira helps long-term care facilities align with Aetna's published turnaround targets and comply with state-mandated minimums. For Aetna's Medicare Advantage and Medicaid managed-care plans, our system supports the phased compliance requirements of CMS-0057-F, aiming for 72-hour standard and 24-hour expedited decisions.

Frequently asked questions

How does Klivira integrate with PointClickCare for Aetna prior authorizations?

Klivira integrates with PointClickCare using its standard APIs to extract relevant resident demographic, clinical, and encounter data. This data then populates Aetna prior authorization requests, reducing manual entry and ensuring accuracy before submission through the appropriate Aetna channel.

Which Aetna prior authorization channels does Klivira support for PointClickCare users?

Klivira supports Aetna's primary medical prior authorization channels, including the Availity provider portal and X12 278 electronic transactions. For pharmacy benefits, we integrate with Aetna's ePA partners, CoverMyMeds and Surescripts, managed by CVS Caremark, covering both retail and mail-order prescriptions.

Can Klivira help long-term care facilities manage Aetna's Clinical Policy Bulletins (CPBs)?

Yes, Klivira's platform helps prior authorization teams navigate Aetna's Clinical Policy Bulletins (CPBs) by providing a structured workflow for request submission. This ensures that documentation for services, often detailed in CPBs, is complete and aligns with Aetna's medical necessity criteria, reducing the likelihood of denials.

Does Klivira assist with prior authorizations for Aetna Medicare Advantage plans?

Absolutely. Klivira's automation platform is designed to support prior authorizations for Aetna Medicare Advantage plans, which are impacted by CMS-0057-F. Our system helps facilities meet the electronic prior authorization and decision-timeframe requirements for these critical plans.

How does automation impact denial rates for Aetna prior authorizations from PointClickCare?

By automating data extraction from PointClickCare and ensuring requests are accurately formatted and routed to Aetna, Klivira helps address common denial reasons such as insufficient documentation or incorrect submission channels. Our goal is to improve the quality and completeness of submissions, which can positively impact approval rates.