Streamlining Fidelis Care Prior Authorization Automation

The Challenge of Manual Prior Authorizations for Fidelis Care

For healthcare providers serving Fidelis Care members in New York, manual prior authorization workflows are a significant operational bottleneck. The process involves labor-intensive steps, from manually checking payer requirements and assembling documentation to tracking decisions across various portals or phone calls. This often results in missed PA-required orders, documentation gaps, and prolonged decision times, directly impacting revenue cycles and patient care.

Klivira's Automated Workflow for Fidelis Care PAs

Klivira transforms the traditional, manual PA process into an automated, EMR-integrated workflow specifically designed to manage the intricacies of payers like Fidelis Care. Our platform ensures that prior authorization requests are initiated, submitted, and tracked with maximum efficiency, reducing administrative burden and accelerating decision timelines.

Key Automation Capabilities for Fidelis Care Prior Authorizations

• **EMR-Side Detection:** Klivira utilizes CDS Hook events from your EMR at order entry to immediately identify Fidelis Care PA requirements, eliminating missed authorizations.
• **Automated Documentation Assembly:** Our system reads FHIR resources from the EMR (e.g., clinical notes, lab results) to assemble comprehensive documentation packets tailored to Fidelis Care's criteria.
• **Payer-Specific Submission Routing:** Klivira intelligently routes requests through the optimal channel for Fidelis Care, including Da Vinci PAS API where available, X12 278 via clearinghouse, provider portal automation, or fax fallback.
• **Real-Time Decision Tracking:** We poll payer endpoints or receive webhooks to provide real-time status updates on Fidelis Care authorizations, surfacing changes directly into your EMR.
• **Denial and Appeal Automation:** Klivira parses denial reasons and routes cases for auto-appeal, human review, or peer-to-peer scheduling, with automated appeal packet assembly and timely-filing tracking.

Navigating Fidelis Care's Submission Channels and Requirements

As a Centene-owned Medicaid and Medicare plan, Fidelis Care's prior authorization requirements can vary by line of business and service type. Klivira's platform is built to adapt to these nuances, ensuring requests are submitted via the correct channel—whether that involves a specific provider portal, an X12 278 EDI transaction, or a Da Vinci PAS API. Our system prioritizes electronic submission to maximize efficiency and adherence to payer protocols.

Compliance and Efficiency for New York Medicaid/Medicare Plans

The federal interoperability and prior authorization final rule (CMS-0057-F) directly impacts Medicaid managed care organizations like Fidelis Care. Klivira's automation helps providers meet mandated decision timeframes (e.g., 72 hours for standard, 24 hours for expedited requests) and ensures timely-filing for appeals. This comprehensive approach supports compliance while significantly improving operational efficiency for Fidelis Care patients.