Accelerate Practice Fusion Highmark Prior Authorization Automation

The Challenge of Highmark PA in Practice Fusion Workflows

Small primary-care practices leveraging Practice Fusion face unique challenges when managing prior authorizations for Highmark. The current process often necessitates manual data entry into the Availity Essentials portal or managing X12 278 transactions, pulling critical patient information from Practice Fusion's chart anatomy, including the Patient Chart and Documents sections. This fragmented workflow consumes staff time and introduces potential for errors.

Klivira's Integration with Practice Fusion

Klivira integrates with Practice Fusion by leveraging its available FHIR R4 read APIs, part of the Veradigm Developer Program. This allows our platform to securely access necessary clinical data for prior authorization requests directly from the EMR, minimizing manual abstraction. While Practice Fusion's write-back capabilities are more limited, Klivira optimizes the outbound data flow to payers, ensuring comprehensive and accurate submissions.

Navigating Highmark's Diverse Submission Channels

Highmark, serving providers in Pennsylvania, West Virginia, Delaware, and Western New York, utilizes various channels for prior authorization. Medical benefit PA submissions for commercial and Medicare Advantage plans are primarily routed through Availity Essentials or via X12 278 transactions through clearinghouses. For specialized services like advanced imaging, cardiology, or musculoskeletal procedures, Highmark employs specialty benefit-management vendors. Klivira centralizes these disparate submission paths.

Automating Key Prior Authorization Workflows

Klivira's platform automates the critical steps in the prior authorization process for Highmark. This includes intelligently extracting clinical documentation from Practice Fusion, populating payer-specific forms (including those for Availity), and submitting requests through the appropriate channels. We also facilitate the management of utilization-management policy access, drawing from Highmark's published medical-policy and clinical-UM-guideline libraries.

Key Benefits for Practice Fusion Users Submitting to Highmark

• Automated data extraction from Practice Fusion via FHIR API.
• Streamlined submission to Highmark's Availity Essentials portal and X12 278 channels.
• Reduced manual data entry and improved accuracy for PA requests.
• Faster turnaround times compliant with state-specific mandates and CMS-0057-F.
• Centralized tracking and management of all Highmark prior authorizations.
• Enhanced staff productivity, allowing focus on patient care rather than administrative tasks.

Compliance and Regulatory Considerations for Highmark PA

Klivira's platform helps practices maintain compliance with evolving regulatory requirements. For Highmark, this includes adherence to state-mandated minimum turnaround times across PA, WV, DE, and NY. Furthermore, for Highmark's Medicare Advantage, Medicaid managed-care, and QHP-on-FFM lines, Klivira supports compliance with the interoperability and prior authorization requirements outlined in CMS-0057-F. Practices should consult with their compliance teams regarding specific implementation details.