Streamlining Practice EHR Medicare Prior Authorization Automation

Klivira delivers robust Practice EHR Medicare prior authorization automation, optimizing workflows for small ambulatory practices navigating the specific requirements of Traditional Medicare and Part D.

For revenue cycle directors and prior authorization coordinators at small ambulatory practices utilizing Practice EHR, managing Medicare prior authorizations presents distinct operational challenges. While Original Medicare's PA scope is limited, the complexity of specific programs and varying MAC requirements demands a precise, automated approach to avoid delays and denials.

Navigating Medicare Prior Authorization within Practice EHR Workflows

Traditional Medicare prior authorization requirements are highly specific, often tied to particular services or Durable Medical Equipment (DME), and managed by various Medicare Administrative Contractors (MACs). Submitting these requests manually from Practice EHR can be time-consuming, requiring staff to navigate multiple MAC portals or specialized forms, leading to potential errors and workflow bottlenecks. Klivira addresses this by centralizing and automating these diverse submission pathways.

Seamless Integration with Practice EHR APIs

Klivira integrates directly with Practice EHR via its robust Practice EHR APIs. This deep integration allows for the seamless initiation of prior authorization requests directly from the patient chart, eliminating duplicate data entry and ensuring that all necessary clinical documentation is accurately captured and transmitted. Our platform acts as an intelligent extension of your Practice EHR environment, maintaining data integrity and security for ePHI.

Optimizing Submissions to Medicare Administrative Contractors (MACs)

For services requiring prior authorization under Traditional Medicare, submissions are routed through the responsible MAC for the provider's specific jurisdiction. Klivira's MAC-aware routing logic supports direct connectivity to all major MACs, including Noridian, NGS, WPS, Palmetto, FCSO, and Novitas. This ensures that each request is directed to the correct contractor with the appropriate jurisdictional specifics, reducing submission errors and accelerating processing.

Specific Traditional Medicare PA Programs Supported

Outpatient Department services prior authorization for specific services (CMS PA model for hospital outpatient services).
Durable Medical Equipment (DME) prior authorization, including PMD demonstration and post-demo expanded lists.
Repetitive Scheduled Non-Emergent Ambulance Transport prior authorization in specific states.
Prior authorization or notification for specific home health, hospice, and post-acute services.

Streamlining Medicare Part D Pharmacy Prior Authorizations

Medicare Part D plans, administered by commercial insurers, govern pharmacy prior authorizations based on CMS-approved formularies and step-therapy protocols. Klivira facilitates electronic pharmacy prior authorization (ePA) submissions for Part D medications. Our platform connects to PBMs and supports the NCPDP SCRIPT standard, streamlining the process for high-cost or specialty drugs that often require extensive documentation.

Policy Adherence with National and Local Coverage Determinations

Klivira incorporates intelligence from both National Coverage Determinations (NCDs) published by CMS and Local Coverage Determinations (LCDs) issued by individual MACs. Our system helps ensure that prior authorization requests initiated from Practice EHR align with current medical necessity criteria, referencing specific NCD numbers or LCD IDs, MAC jurisdiction, and effective dates. This proactive policy adherence minimizes the risk of denials due to non-compliance.

Frequently asked questions

How does Klivira handle the limited scope of Original Medicare prior authorizations?

While Original Medicare has a narrower PA scope than Medicare Advantage, Klivira's platform is designed to identify and automate PA for the specific services that do require it, such as certain outpatient services, DME, and ambulance transport. For services not requiring PA, the system ensures no unnecessary requests are generated, maintaining efficient workflows.

Can Klivira integrate directly with my Practice EHR system?

Yes, Klivira integrates directly with Practice EHR using its robust Practice EHR APIs. This enables prior authorization requests to be initiated from within your existing EMR workflow, pulling relevant patient data and clinical documentation seamlessly without requiring manual data entry in external portals.

How does Klivira ensure submissions go to the correct Medicare Administrative Contractor (MAC)?

Klivira employs MAC-aware routing logic that automatically identifies the correct Medicare Administrative Contractor (MAC) based on the provider's jurisdiction and the service being requested. Our platform maintains direct connectivity with all major MACs, including Noridian, NGS, WPS, Palmetto, FCSO, and Novitas, ensuring accurate and compliant submission.

Does Klivira assist with Medicare Part D pharmacy prior authorizations?

Yes, Klivira supports electronic pharmacy prior authorization (ePA) for Medicare Part D medications. We connect to Pharmacy Benefit Managers (PBMs) and utilize the NCPDP SCRIPT standard to streamline the submission process, helping your practice efficiently manage PA for specialty drugs or those requiring step therapy protocols.

How does Klivira keep up with changing Medicare policies like NCDs and LCDs?

Klivira continuously updates its policy library to reflect current National Coverage Determinations (NCDs) from CMS and Local Coverage Determinations (LCDs) from individual MACs. Our system incorporates these criteria into the automation workflow, providing guidance and ensuring that submitted requests align with the most recent medical necessity guidelines, citing specific policy IDs and effective dates.