Streamlining Cardiology Prior Authorization with Cognizant TriZetto

The Challenge of Cardiology Prior Authorizations via Clearinghouses

Cardiology PA often involves intricate clinical criteria from bodies like ACC/AHA and ACR, alongside specific payer policies. While Cognizant TriZetto serves as a vital clearinghouse and payer platform for claims and authorizations, the underlying complexity of cardiology PA—including routing to specialty benefit-management vendors for advanced imaging—demands a sophisticated front-end solution. Klivira bridges this gap, preparing and submitting robust PA requests that meet these diverse requirements before they reach the clearinghouse.

High-Volume Cardiology PA Categories Managed Through TriZetto

• **Advanced Cardiac Imaging:** Cardiac MRI, cardiac CT angiography (CCTA), nuclear stress imaging, and PET cardiac viability, often routed through specialty benefit managers.
• **Interventional Procedures:** Diagnostic cardiac catheterization, percutaneous coronary intervention (PCI), and structural-heart procedures (TAVR, MitraClip, LAA closure).
• **Electrophysiology Procedures:** ICDs, CRT devices, pacemakers, and ablation procedures for atrial fibrillation or ventricular tachycardia.
• **Specialty Cardiovascular Drugs:** PCSK9 inhibitors, sacubitril/valsartan, SGLT2 inhibitors for heart failure, and mavacamten, requiring detailed step-therapy documentation.

Navigating Clinical Guidelines and Documentation for Cardiology PA

Accurate documentation aligned with ACC/AHA guidelines and ACR Appropriateness Criteria is paramount for cardiology PA success. Klivira's platform incorporates policy logic to guide PA coordinators in compiling the necessary clinical evidence—such as ejection fraction, NYHA functional class, prior imaging results, and optimal medical therapy duration—ensuring that requests submitted via Cognizant TriZetto are complete and evidence-based from the outset. This proactive approach significantly reduces the likelihood of denials due to insufficient clinical detail.

Mitigating Common Cardiology PA Denials via Optimized Workflows

Common cardiology PA denial reasons include inappropriate use criteria for imaging, step therapy violations, and documentation gaps for device eligibility (e.g., EF/NYHA class). Klivira's system performs pre-submission checks against known payer logic and clinical guidelines, identifying potential denial triggers before the request is sent to Cognizant TriZetto. By ensuring compliance with site-of-service rules or confirming optimal medical therapy duration, Klivira helps prevent costly delays and rework.

Klivira's Connectivity for Cardiology PA Workflows

• **EMR Integration:** Bi-directional integration with major EMRs via SMART on FHIR, capturing clinical data directly from cardiology templates.
• **Cognizant TriZetto Submissions:** Automated routing and submission of X12 278 transactions and attachments through TriZetto.
• **Payer Portal & Specialty Vendor Connectivity:** Direct connectivity to payer portals and automatic identification/routing to specialty benefit-management vendors (e.g., Carelon MBM, eviCore / successor vendors, NIA/Magellan) when required for cardiac imaging.
• **Policy Library Access:** Continuous updates to payer-specific policies, including those related to cardiology, ensuring current criteria are applied.

Enhancing Operational Efficiency in Cardiology Revenue Cycle

By automating the prior authorization process, Klivira empowers cardiology practices to improve turnaround times for critical cardiac services. This efficiency extends beyond initial submission, encompassing automated status checks and proactive alerts for urgent presentations like suspected ACS. For revenue cycle directors, this translates to reduced administrative costs, improved claim cleanliness, and a healthier revenue stream, while PA coordinators can focus on complex cases requiring clinical judgment rather than manual data entry.