Optimizing Highmark Prior Authorization Automation with Klivira

Klivira delivers comprehensive Highmark prior authorization automation, transforming manual, fragmented workflows into an efficient, integrated process. Our platform directly addresses the complexities of Highmark's diverse submission channels and policy requirements.

Navigating prior authorizations for Highmark's commercial, Medicare Advantage, and Medicaid managed-care plans across Pennsylvania, West Virginia, Delaware, and New York presents significant administrative challenges. Manual processes lead to delays, increased denials, and staff burnout. Klivira's automation solution is engineered to streamline every step, from initial order to final approval, ensuring compliance and accelerating patient care.

Navigating Highmark's Diverse Prior Authorization Channels

Highmark routes most medical-benefit prior authorization submissions for commercial and Medicare Advantage plans through Availity Essentials. Klivira automates submissions directly via Availity, while also supporting X12 278 transactions through clearinghouses for impacted procedures. For pharmacy prior authorizations, Klivira adapts to the specific PBM relationships, which require verification, to ensure comprehensive coverage. Our system also accounts for state-specific operational nuances across Highmark's service areas in PA, WV, DE, and Western NY.

Klivira's Automated Workflow for Highmark PAs

**EMR-Side Detection:** Klivira identifies Highmark PA requirements at the point of order entry in your EMR using CDS Hooks and Da Vinci CRD-style logic, preventing missed authorizations.
**Automated Documentation Assembly:** Our platform pulls clinical notes, imaging reports, and other necessary FHIR resources from the EMR, assembling a complete documentation packet tailored to Highmark's published criteria.
**Intelligent Submission Routing:** Klivira routes requests through the optimal channel for Highmark: direct submission via Availity, X12 278 via clearinghouse, or Da Vinci PAS API where Highmark supports it, with fax as a last resort.
**Real-time Status Tracking & Write-back:** Klivira polls Highmark's Availity portal or processes X12 278 responses for real-time status updates, writing authorization numbers directly back to the EMR upon approval.
**Denial Routing & Appeal Automation:** On denial, Klivira parses the reason, routing cases for auto-appeal, human review, or peer-to-peer scheduling, and automates appeal packet assembly and submission.

Leveraging Highmark's Policy Libraries for Precision Automation

Klivira's payer policy engine ingests and continuously updates its rules from Highmark's published medical-policy and clinical-UM-guideline libraries. This ensures that our automation accurately reflects Highmark's latest coverage criteria, enabling precise PA requirement detection and documentation assembly. By automating against these specific guidelines, we minimize manual review and reduce the likelihood of denials due to policy discrepancies.

Compliance and Timelines: Highmark and CMS-0057-F

Klivira's platform supports adherence to both state-mandated minimum prior authorization turnaround times across Pennsylvania, West Virginia, Delaware, and New York, and federal requirements. For Highmark's Medicare Advantage, Medicaid managed-care, and any Qualified Health Plan (QHP) on the Federal Facilitated Marketplace (FFM) lines, Klivira's workflow is aligned with CMS-0057-F. This ensures that standard PA decisions are processed within the 72-hour timeframe and expedited requests within 24 hours, enhancing compliance and patient access.

Addressing Highmark PA Friction Points

Klivira's automation directly tackles common friction points in Highmark prior authorization workflows. This includes eliminating missed PA-required orders at detection, minimizing documentation gaps that trigger callbacks, and preventing lost-to-follow-up appeals or timely-filing breaches. By standardizing channel selection and automating authorization number write-back to the EMR, we ensure that administrative errors are drastically reduced, leading to faster approvals and a more predictable revenue cycle.

Frequently asked questions

How does Klivira automate Highmark PA submissions?

Klivira automates Highmark PA submissions by intelligently routing requests through the appropriate channel, including direct integration with Availity Essentials, X12 278 transactions via clearinghouses, and Da Vinci PAS API where supported. Our system selects the most efficient electronic pathway for each specific request.

What Highmark lines of business are covered by Klivira's automation?

Klivira's automation covers Highmark's commercial, Medicare Advantage, and Medicaid managed-care lines of business. Our platform is designed to adapt to the specific rules and submission channels required for each, including considerations for CMS-0057-F for applicable plans.

How does Klivira ensure compliance with Highmark's state-specific PA rules?

Klivira's payer policy engine incorporates Highmark's state-specific medical policies and clinical guidelines for Pennsylvania, West Virginia, Delaware, and New York. This ensures that PA requirement detection and documentation assembly are tailored to the precise rules of the relevant jurisdiction, aiding compliance with local regulations.

Does Klivira integrate with Availity for Highmark prior authorizations?

Yes, Klivira integrates directly with Availity Essentials, which Highmark utilizes for most medical-benefit PA submissions. This integration allows for automated submission, real-time status polling, and efficient management of prior authorization requests through Highmark's preferred provider portal.

Can Klivira automate pharmacy prior authorizations for Highmark?

Klivira's platform is capable of automating pharmacy prior authorizations. For Highmark, this involves adapting to the specific PBM relationships and their associated submission channels, which are verified to ensure seamless integration and efficient processing of pharmacy benefit requests.