PointClickCare UnitedHealthcare Prior Authorization Automation for Long-Term Care

Bridging PointClickCare Workflows with UnitedHealthcare's PA Channels

PointClickCare (PCC) serves as the core EMR for long-term care, SNFs, and senior living facilities. Submitting prior authorizations to UnitedHealthcare (UHC) from PCC often involves manual transfers to UHCprovider.com, X12 278 transactions, or ePA partners. Klivira integrates directly with PointClickCare APIs to capture necessary clinical and demographic data, automating the preparation and submission of prior authorization requests to UnitedHealthcare.

Automating Submissions Across UnitedHealthcare's Diverse Ecosystem

UnitedHealthcare manages prior authorizations through multiple channels, each with specific requirements. Klivira's platform is engineered to connect to these diverse endpoints, ensuring your requests are routed correctly and efficiently. This includes medical benefit PAs, pharmacy benefit PAs via OptumRx, and inpatient admission notifications critical for long-term care settings.

Key UnitedHealthcare PA Submission Channels Supported:

• **UHCprovider.com:** Direct submission to UnitedHealthcare's primary provider portal for medical-benefit prior authorizations and advance notifications.
• **X12 278 Transactions:** Support for electronic submissions via clearinghouses for applicable procedures, reducing manual data entry.
• **OptumRx ePA Partners:** Integration with CoverMyMeds and Surescripts for pharmacy-benefit prior authorizations handled by OptumRx.
• **Inpatient Admission Notification:** Streamlined submission of concurrent review and continued-stay reviews, aligned with UHC's documented processes.

Navigating Specialty Drug PAs and Policy Criteria for Senior Care

For long-term care patients, managing specialty drug prior authorizations, whether under the medical or pharmacy benefit (OptumRx), is complex due to therapeutic-class specific splits and site-of-care policies. Klivira helps consolidate the necessary documentation from PointClickCare to meet UHC's medical necessity criteria, often referencing their Medical Policy Library, MCG, or NCCN compendium for oncology. This ensures that high-cost medications and infusions receive timely approvals.

Compliance and Turnaround Time Considerations with UnitedHealthcare

UnitedHealthcare's prior authorization turnaround times are influenced by state regulations, NCQA Utilization Management accreditation standards, and, for its Medicare Advantage and UnitedHealthcare Community Plan lines, by CMS-0057-F. Klivira's automation helps your facility align with these varied requirements, facilitating faster decision-making for standard and expedited PAs and reducing the administrative burden associated with compliance tracking. (Note: UHC's commercial book is not directly impacted by CMS-0057-F.)

Proactive Denial Management and Appeals for UHC Submissions

Common UnitedHealthcare denial reasons, such as insufficient clinical documentation or site-of-service mismatch, can significantly impact revenue for long-term care facilities. Klivira's platform supports robust documentation capture from PointClickCare to proactively address these issues. In cases of denial, our system helps track and manage the appeal pathway, including peer-to-peer reviews, ensuring all necessary steps are taken to overturn unfavorable decisions.