PointClickCare Medicare Prior Authorization Automation for SNFs & Senior Living

Klivira delivers robust PointClickCare Medicare prior authorization automation, specifically designed to streamline the complex workflows inherent in long-term care and skilled nursing facilities. This integration reduces administrative overhead and accelerates critical care delivery.

Managing prior authorizations for Medicare beneficiaries within PointClickCare often involves navigating disparate MAC portals and understanding nuanced coverage rules. For SNFs and senior living providers, this manual process can delay essential services and strain revenue cycles. Klivira addresses these challenges by integrating directly with PointClickCare and automating Medicare PA submissions.

Streamlining Medicare PA from PointClickCare

For long-term care and senior living facilities using PointClickCare, submitting prior authorizations to Original Medicare's various Administrative Contractors (MACs) is a significant operational challenge. Manual data entry from PCC into individual MAC portals like Noridian, NGS, or WPS consumes valuable staff time and introduces potential for errors, impacting care continuity and reimbursement.

Klivira's Seamless Integration with PointClickCare and Medicare

Klivira leverages PointClickCare APIs to extract necessary patient and service data directly, eliminating redundant data entry. For Medicare PA, our platform routes requests through the appropriate MAC contractor, such as Palmetto or Novitas, ensuring jurisdictional compliance and efficient processing for services requiring prior authorization under Original Medicare.

Targeted Prior Authorization Workflows for Senior Care

While Original Medicare's prior authorization scope is limited, it applies to critical services common in long-term care. This includes specific Outpatient Department services, Durable Medical Equipment (DME), and repetitive scheduled non-emergent ambulance transport. Klivira’s MAC-aware routing and NCD/LCD policy logic ensure submissions align with specific program requirements and coverage determinations.

Key Medicare PA Programs Supported

Outpatient Department services prior authorization (CMS PA model for hospital outpatient services).
Durable Medical Equipment (DME) prior authorization, including power mobility devices.
Repetitive Scheduled Non-Emergent Ambulance Transport (RSNAT) prior authorization in specific states.
Specific home health, hospice, and post-acute services with prior authorization or notification.
Medicare Part D pharmacy prior authorizations (routed to commercial plan PBMs).

Navigating Medicare Coverage Policies

Klivira integrates National Coverage Determinations (NCDs) and Local Coverage Determinations (LCDs) published by MACs into its policy engine. This ensures that prior authorization requests initiated within PointClickCare are automatically checked against the latest Medicare guidelines, reducing denials and the need for appeals. Providers should consult their compliance teams regarding specific NCD/LCD applicability.

Frequently asked questions

How does Klivira connect with PointClickCare for Medicare PA?

Klivira integrates directly with PointClickCare using its established APIs, allowing for secure, automated extraction of patient demographics, clinical documentation, and order details relevant to prior authorization requests. This eliminates manual data transfer from PCC to external MAC portals.

What types of Medicare prior authorizations does Klivira automate for PCC users?

Klivira automates prior authorizations for services requiring it under Original Medicare, such as specific Outpatient Department services, Durable Medical Equipment (DME), and repetitive non-emergent ambulance transport. For Medicare Part D, Klivira routes pharmacy PA requests to the respective commercial plans' PBMs.

Does Klivira handle Medicare Advantage (MA) prior authorizations for PointClickCare?

While this page focuses on Original Medicare, Klivira also supports Medicare Advantage prior authorizations. MA plans, run by private insurers, have expanded PA requirements, and Klivira connects to these plans' portals and ePA channels, integrating seamlessly with PointClickCare.

How does Klivira ensure the correct MAC is used for Medicare PA submissions?

Klivira’s system incorporates MAC-aware routing logic. Based on the provider's jurisdiction and the specific service, the platform automatically identifies and directs the prior authorization request to the responsible Medicare Administrative Contractor (e.g., Noridian, NGS, WPS).

Can Klivira help with Medicare Part D pharmacy prior authorizations?

Yes, for Medicare Part D, which is administered by private plans, Klivira facilitates pharmacy prior authorizations by connecting to the relevant commercial insurers and their PBMs, aligning with CMS-approved formularies and step-therapy protocols.