Automating Medicare Imaging Prior Auth for Advanced Radiology

Klivira streamlines Medicare imaging prior auth processes, ensuring compliance with federal and MAC-specific requirements for advanced radiology services.

Navigating prior authorization for Medicare imaging can be complex, especially with varying requirements across Original Medicare (Fee-for-Service) and Medicare Advantage plans. Revenue cycle and prior authorization teams face challenges in accurately identifying when PA is required, which entity to submit to, and adhering to specific coverage policies.

The Nuance of Medicare Imaging Prior Authorization

Original Medicare (Fee-for-Service) has a limited scope for advanced imaging prior authorization, primarily handled by Medicare Administrative Contractors (MACs) such as Noridian, NGS, and Novitas. Unlike many commercial plans, widespread advanced imaging PA through radiology benefit managers is not typical for Original Medicare. Klivira's platform is designed to accurately identify these specific, limited PA requirements and route submissions accordingly, adhering to National Coverage Determinations (NCDs) and Local Coverage Determinations (LCDs).

Navigating Original Medicare Imaging PA Challenges

Accurately identifying the limited advanced imaging services requiring PA under Original Medicare, such as specific Outpatient Department services.
Determining the correct MAC jurisdiction and its specific submission protocols for services like DME prior authorization.
Interpreting and applying CMS-published NCDs and MAC-issued LCDs for medical necessity criteria.
Managing varied submission channels, which may include MAC portals or X12 278 transactions, depending on the service and MAC.

Klivira's Automated Solution for Medicare Imaging Prior Auth

Klivira automates the detection and submission process for applicable Medicare imaging prior authorizations. Leveraging EMR integration, our platform identifies when a PA is required for an advanced imaging order under Original Medicare's specific programs, routing the request to the correct MAC contractor. This ensures compliance with jurisdictional requirements and NCD/LCD guidelines, minimizing manual lookups and potential errors.

Leveraging NCDs and LCDs for Policy Adherence

For Medicare imaging prior auth, medical necessity is governed by CMS-published National Coverage Determinations (NCDs) and MAC-issued Local Coverage Determinations (LCDs). Klivira incorporates this policy intelligence, ensuring that submissions are aligned with the relevant NCD number or LCD ID, MAC jurisdiction, and effective dates. This pre-submission validation helps reduce denials based on coverage criteria.

Addressing the Broader Medicare Landscape: Advantage Plans and RBMs

While Original Medicare's imaging PA is limited, Medicare Advantage (MA) plans, administered by private insurers, often utilize a broader scope of prior authorization for advanced imaging, frequently involving radiology benefit managers such as eviCore, NIA Magellan, or AIM Specialty Health. Klivira's platform provides comprehensive connectivity to these RBMs and MA payer portals, automating submissions and applying ACR Appropriateness Criteria-aware checks for these expanded requirements.

Streamlining Workflow and Reducing Administrative Burden

Klivira's automation for Medicare imaging prior auth begins with EMR-side detection via CDS Hooks at order entry, surfacing PA requirements instantly. This reduces missed PAs and manual vendor identification errors. By automating data extraction and submission to MACs or RBMs (for MA plans), and incorporating pre-submission appropriateness checks, we accelerate the PA cycle and free up staff from repetitive manual tasks.

Frequently asked questions

Does Original Medicare require prior authorization for all advanced imaging?

No, Original Medicare (Fee-for-Service) has a limited scope for prior authorization on advanced imaging services. PA is typically required for specific services, such as certain outpatient department procedures or DME, rather than a broad mandate for all advanced radiology. Klivira helps identify these specific requirements.

How does Klivira identify the correct submission channel for Medicare imaging PA?

Klivira's platform uses payer and member plan data to automatically identify the responsible Medicare Administrative Contractor (MAC) for Original Medicare PA. For Medicare Advantage plans, it routes to the specific plan's portal or designated radiology benefit manager (e.g., eviCore, NIA Magellan, AIM Specialty Health), ensuring accurate and efficient submission.

What role do NCDs and LCDs play in Medicare imaging prior auth?

National Coverage Determinations (NCDs) from CMS and Local Coverage Determinations (LCDs) from MACs define the medical necessity criteria for services covered by Medicare. Klivira integrates these policy libraries, ensuring that imaging prior authorization submissions are aligned with the specific NCD or LCD requirements for coverage.

Can Klivira integrate with my EMR for Medicare imaging PA?

Yes, Klivira integrates with leading EMR systems via standards like SMART on FHIR and CDS Hooks. This enables automated detection of Medicare imaging PA requirements at the point of order entry, streamlining data capture and initiating the prior authorization workflow directly from your clinical system.

How does Klivira handle radiology benefit managers for Medicare imaging?

While radiology benefit managers (RBMs) like eviCore or NIA Magellan are less common for Original Medicare imaging PA, they are frequently utilized by Medicare Advantage (MA) plans. Klivira automates submissions to these RBMs for MA members, including pre-submission checks against ACR Appropriateness Criteria, reducing manual portal interactions.