Streamlining Medicare Prior Authorization Workflows with Epic Orchestrate

Klivira directly integrates Medicare prior authorization workflows into Epic Orchestrate, providing a unified, Epic-native workflow surface for managing federal payer requirements.

Navigating prior authorizations for Original Medicare can be complex due to its limited scope and the varied requirements of Medicare Administrative Contractors (MACs). Integrating these specific processes into Epic Orchestrate enables a more streamlined and consistent approach for your revenue cycle teams and prior authorization coordinators.

Integrating Medicare PA Logic into Epic Orchestrate

Klivira extends Epic Orchestrate's capabilities by embedding MAC-aware routing and NCD/LCD-driven policy logic directly into your existing Epic workflow. This ensures that when prior authorization is required for Original Medicare services, the process is initiated and managed efficiently from within the Hyperdrive Orchestrate environment, minimizing manual effort and reducing context switching.

Specific Medicare Prior Authorization Programs Supported

While Original Medicare has a narrower scope for prior authorization compared to Medicare Advantage plans, specific services and programs do require it. Klivira's integration with Epic Orchestrate supports these critical areas, ensuring compliance and timely submissions.

Key Original Medicare PA Scenarios Handled:

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 certain home health, hospice, and post-acute services.

Policy Adherence and Documentation within Epic Orchestrate

Accurate clinical documentation and adherence to coverage policies are paramount for Medicare prior authorizations. Klivira facilitates the referencing of National Coverage Determinations (NCDs) and MAC-published Local Coverage Determinations (LCDs) directly within the Epic Orchestrate workflow. This ensures that required citations, including the specific NCD number or LCD ID, MAC jurisdiction (e.g., Noridian, NGS, WPS), and effective date, are readily available for submission.

Optimizing Submission Channels for Original Medicare PA

For Traditional Medicare members, prior authorization submissions route through the responsible Medicare Administrative Contractor (MAC) for the provider's jurisdiction. Klivira’s MAC-aware routing engine ensures that requests are directed to the correct channels, whether through specific MAC portals or other designated submission methods, directly from your Epic Orchestrate interface. This targeted approach is crucial given the limited applicability of broad ePA or X12 278 standards for Original Medicare PA.

Turnaround Time Considerations for Medicare PA

Medicare prior authorization programs have specific, documented timeframes for review. While CMS-0057-F primarily impacts Medicare Advantage and other managed care plans, Original Medicare PA programs adhere to their own established turnaround norms. Klivira's integration helps track these program-specific deadlines within Epic Orchestrate, providing visibility and supporting timely follow-up to meet federal requirements.

Frequently asked questions

What is the scope of prior authorization for Original Medicare services?

Prior authorization under Original Medicare (Parts A and B) is limited to specific services and programs, unlike the broader scope found in Medicare Advantage plans. Klivira focuses on automating these specific, required PAs, such as for certain outpatient department services, DME, and repetitive non-emergent ambulance transport.

How does Klivira handle MAC-specific requirements within Epic Orchestrate?

Klivira's integration provides MAC-aware routing, directing prior authorization requests to the correct Medicare Administrative Contractor (MAC) based on the provider's jurisdiction. This ensures that submissions adhere to the specific requirements and channels of MACs like Noridian, NGS, WPS, Palmetto, FCSO, or Novitas, all managed within your Epic Orchestrate workflow.

Are Medicare Part D pharmacy prior authorizations managed through this integration?

Medicare Part D pharmacy prior authorizations are administered by commercial insurers as private contractors. While Klivira supports pharmacy PA for various payers, the specific Part D process is distinct from Part A and B medical PA handled by MACs, following CMS-approved plan formularies and step-therapy protocols.

What policy documentation is surfaced for Medicare PA via Epic Orchestrate?

The integration surfaces National Coverage Determinations (NCDs) published by CMS and Local Coverage Determinations (LCDs) published by the responsible MAC. This ensures that your team can cite the specific NCD number or LCD ID, MAC jurisdiction, and effective date required for compliant prior authorization submissions, directly within the Epic Orchestrate environment.

Does CMS-0057-F apply to Original Medicare PA processed via Epic Orchestrate?

The CMS-0057-F rule primarily affects Medicare Advantage, Medicaid managed care, CHIP, and Qualified Health Plans on the Federally Facilitated Marketplace. Its applicability to Original Medicare (Traditional Medicare) prior authorization programs is limited, which means Original Medicare PA programs follow their own established timeframes and guidelines.