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Optimizing Cardiology Prior Authorization with Epic Orchestrate

Klivira enhances **cardiology Epic Orchestrate** workflows, embedding prior authorization automation directly into your Epic EMR for advanced cardiac procedures, imaging, and specialty drugs.

Revenue cycle directors and prior authorization coordinators in cardiology face significant challenges, from high-volume imaging PAs to complex interventional and specialty drug approvals. Integrating PA automation within Epic Orchestrate offers a strategic advantage, transforming a traditionally manual, high-friction process into an efficient, EMR-native workflow. Klivira leverages Epic Orchestrate to streamline these critical operations.

The Challenge of Cardiology Prior Authorization

Cardiology is characterized by a high volume of prior authorization requests, particularly for advanced cardiac imaging, interventional procedures, and specialty cardiovascular drugs. These often involve intricate clinical criteria, multiple payer channels, and the frequent involvement of specialty benefit-management vendors, leading to significant administrative burden and potential delays in patient care. Efficiently navigating these requirements is paramount for both financial health and patient outcomes.

Key Cardiology PA Triggers in the Epic Orchestrate Workflow

Within an Epic Orchestrate environment, Klivira targets the most common prior authorization triggers in cardiology. This includes advanced cardiac imaging such as nuclear stress imaging, cardiac MRI, and CCTA, which are frequently routed through specialty benefit managers. We also automate authorizations for interventional procedures like cardiac catheterization, PCI, and electrophysiology procedures (ICDs, ablations), alongside specialty cardiovascular drugs like PCSK9 inhibitors and sacubitril/valsartan, ensuring comprehensive coverage across the care continuum.

Embedding Clinical Guidelines for Approval Efficiency

Successful cardiology prior authorizations rely heavily on adherence to established clinical guidelines. Klivira, integrated with Epic Orchestrate, incorporates logic informed by frameworks like the ACC/AHA guidelines and ACR Appropriateness Criteria. This ensures that documentation for critical elements—such as ejection fraction for ICD eligibility, LDL levels for PCSK9 inhibitors, or pre-test probability for advanced imaging—is captured and validated upfront, reducing common denial reasons like 'inappropriate use criteria' or 'documentation gaps'.

Navigating Specialty-Specific Workflow Constraints with Orchestrate

Cardiology workflows present unique PA challenges, including time-sensitive authorizations for urgent presentations and the prevalence of specialty benefit-management vendors (e.g., Carelon MBM, eviCore successor vendors, NIA/Magellan). Klivira's integration with Epic Orchestrate provides automated routing to the correct channel, whether payer-direct or vendor portal, and supports complex sequences like imaging-cath pathways and the longer lead times required for device prior authorizations, such as ICDs and structural-heart procedures.

Klivira's Solution for Cardiology within Epic Orchestrate

Klivira leverages Epic Orchestrate's native capabilities and SMART on FHIR app placement to embed intelligent prior authorization automation directly into the cardiology workflow. Our platform identifies whether a request routes to a specialty benefit manager or payer-direct, applies ACR Appropriateness Criteria-aware policy logic for imaging, and manages the distinct workflows for device and specialty drug PAs. This integration streamlines data capture, submission, and status monitoring, reducing manual intervention and accelerating approvals for critical cardiac care.

Frequently asked questions

How does Klivira's Epic Orchestrate integration handle advanced cardiac imaging PAs?

Klivira automates advanced cardiac imaging PAs by identifying when requests route through specialty benefit-management vendors (e.g., Carelon MBM, eviCore) and applying ACR Appropriateness Criteria-aware policy logic. This ensures that necessary clinical documentation, such as pre-test probability and prior imaging history, is captured within Epic and submitted efficiently via the correct channel, reducing denials related to 'inappropriate use criteria'.

Can Epic Orchestrate manage prior authorizations for specialty cardiovascular drugs?

Yes, Klivira's solution within Epic Orchestrate supports prior authorizations for specialty cardiovascular drugs like PCSK9 inhibitors, sacubitril/valsartan, and SGLT2 inhibitors. Our system incorporates payer-specific step-therapy logic and ensures that required documentation, such as LDL levels on maximum tolerated statins or HFrEF documentation, is present, streamlining the approval process for these high-cost medications.

What role do ACC/AHA guidelines play in Klivira's Epic Orchestrate workflows for cardiology?

ACC/AHA guidelines are foundational to many cardiology prior authorization criteria. Klivira's policy logic, integrated with Epic Orchestrate, is informed by these guidelines to guide users in documenting essential clinical data. This includes ejection fraction for ICD/CRT eligibility, NYHA functional class, and optimal medical therapy duration, helping to prevent denials often linked to 'documentation gaps' or insufficient adherence to guideline-directed medical therapy.

How does Klivira handle specialty benefit managers within Epic Orchestrate for cardiology?

Klivira's integration automatically identifies if a cardiology prior authorization request needs to be routed to a specialty benefit-management vendor (e.g., Carelon MBM, eviCore, NIA/Magellan) rather than directly to the payer. This ensures that the request is sent to the correct portal or channel, leveraging Klivira's deep connectivity to these vendors from within the Epic Orchestrate workflow, eliminating manual portal navigation and data re-entry.

What kind of data does Klivira pull from Epic via Orchestrate for cardiology PA?

Klivira leverages Epic Orchestrate and SMART on FHIR to pull relevant clinical data directly from the patient's EMR. This includes patient demographics, diagnoses (ICD-10-CM), ordered procedures (CPT), medications, lab results (e.g., ejection fraction, LDL levels), and clinical notes. This automated data extraction ensures that prior authorization submissions are comprehensive and aligned with payer requirements, minimizing manual data entry and potential errors.

Related coverage

Other cardiology prior auth workflows

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