Automating PointClickCare Highmark Prior Authorization

Klivira delivers comprehensive PointClickCare Highmark prior authorization automation, specifically designed to reduce administrative overhead for long-term care and senior living facilities. Our platform integrates directly with PointClickCare to streamline the complex process of securing approvals from Highmark.

Revenue cycle directors and prior authorization coordinators in long-term care settings face unique challenges when managing prior authorizations for Highmark members. The manual effort of navigating payer portals like Availity and managing diverse clinical documentation from PointClickCare can lead to delays, denials, and increased operational costs. Klivira addresses these pain points by providing an intelligent, automated solution.

The Challenge: Highmark Prior Auth from PointClickCare

Submitting prior authorizations to Highmark from a PointClickCare environment often involves a multi-step, manual workflow. For medical benefits, Highmark primarily routes submissions through Availity Essentials, alongside accepting X12 278 transactions via clearinghouses for many procedures. This requires staff to extract patient data, clinical notes, and orders from PointClickCare, then re-enter or upload them into external systems, a process prone to errors and delays, particularly for the high volume of services common in long-term care.

Klivira's Integration with PointClickCare

Klivira seamlessly integrates with PointClickCare using its robust APIs. This direct connection enables automated extraction of critical patient demographics, clinical documentation, and order details directly from the EMR. By establishing a real-time data flow, Klivira eliminates manual data entry, ensuring that prior authorization requests are built with accurate and complete information, reducing the risk of administrative denials.

Streamlining Highmark Prior Authorization Submissions

Our platform automates the submission process to Highmark across its primary channels. Klivira supports electronic submissions through Availity Essentials, where Highmark routes most medical-benefit prior authorizations for its commercial and Medicare Advantage plans across Pennsylvania, West Virginia, Delaware, and New York. Additionally, Klivira facilitates X12 278 transactions via clearinghouses, providing a comprehensive solution for Highmark prior authorization requests originating from PointClickCare.

Navigating Highmark's Utilization Management Policies

Highmark publishes extensive medical policy and clinical utilization management guideline libraries through its provider site. Klivira's automation engine is designed to help prior authorization coordinators cross-reference these policies efficiently. For Highmark's Medicare Advantage, Medicaid managed-care, and any Qualified Health Plan (QHP) on the Federally-Facilitated Marketplace (FFM) lines, the requirements of CMS-0057-F regarding electronic prior authorization are also critical considerations for your compliance team.

Key Prior Authorization Workflows for PointClickCare & Highmark

Advanced imaging (e.g., MRI, CT scans) for diagnostic purposes.
Post-acute care services, including skilled nursing facility (SNF) admissions.
Durable Medical Equipment (DME) often required in senior living settings.
Specialty medications, particularly those administered in a long-term care facility.
Physical, occupational, and speech therapy services.
Interventional pain management procedures.

Addressing Specialty Benefit Management for Highmark Patients

Like many major commercial plans, Highmark routes specific clinical domains such as advanced imaging, cardiology, musculoskeletal care, and radiation oncology through specialty benefit-management vendors. While the current vendor scope requires verification at each review cycle, Klivira's flexible architecture helps manage these diverse prior authorization pathways, ensuring requests are directed to the correct entity, even when external vendors are involved.

Frequently asked questions

How does Klivira integrate with PointClickCare for prior authorization?

Klivira integrates directly with PointClickCare via its robust APIs. This connection allows for automated, secure extraction of patient demographics, clinical notes, and order details, eliminating manual data entry and ensuring accurate, complete prior authorization requests.

Which Highmark submission channels does Klivira support?

Klivira supports Highmark's primary prior authorization submission channels, including Availity Essentials for medical-benefit PAs and X12 278 transactions via clearinghouses. This ensures comprehensive coverage for Highmark members across their service areas in PA, WV, DE, and NY.

Is Klivira beneficial for long-term care facilities using PointClickCare for Highmark patients?

Yes, Klivira is specifically beneficial for long-term care facilities. It streamlines prior authorization for services common in SNFs and senior living, such as advanced imaging, post-acute care admissions, and durable medical equipment, which are frequently subject to Highmark's PA requirements.

How does Klivira help with Highmark's medical policies and guidelines?

Klivira's automation helps prior authorization coordinators efficiently cross-reference Highmark's published medical policy and clinical utilization management guidelines. This aids in constructing compliant requests and understanding the specific criteria required for approval, reducing the likelihood of denials.

Does Klivira handle Highmark's use of specialty benefit managers for certain services?

Yes, Klivira's platform is designed to manage diverse prior authorization pathways, including those routed through specialty benefit management vendors for specific clinical domains like advanced imaging or cardiology, as utilized by Highmark. Our system helps ensure requests are directed appropriately.