Automating Fertility (REI) Imaging Prior Auth for Reproductive Care

The Challenge of Imaging PA in Fertility Care

Fertility practices regularly order advanced imaging such as pelvic MRIs, CT scans, and advanced ultrasounds for diagnostics, treatment planning, and monitoring during IVF and other fertility preservation procedures. These orders often trigger prior authorization requirements, frequently routed through radiology benefit managers (RBMs) like eviCore, NIA Magellan, and AIM Specialty Health, adding layers of complexity to an already time-sensitive patient journey.

Common Imaging PA Triggers in Reproductive Endocrinology

• Pelvic MRI for uterine anomalies, endometriosis mapping, or ovarian assessment.
• CT scans for specific diagnostic evaluations related to reproductive health.
• Advanced ultrasound (e.g., 3D ultrasound) for detailed uterine cavity or ovarian imaging.
• Nuclear imaging in rare cases for specific diagnostic pathways.
• Imaging required as part of a workup for IVF cycles or fertility preservation procedures.

Navigating Radiology Benefit Managers for Fertility Imaging

The landscape for imaging prior authorization in fertility care is complicated by the prevalence of RBMs. Clinicians and staff must accurately identify which RBM (e.g., eviCore, NIA Magellan, Carelon Medical Benefits Management) is responsible for a given payer and member plan, then navigate their specific provider portals and clinical criteria. Submissions often require detailed documentation of clinical questions, ICD-10 diagnoses, and prior imaging history, which are then evaluated against frameworks like ACR Appropriateness Criteria.

Klivira's Automated Approach to Fertility Imaging Prior Auth

Klivira integrates directly with your EMR, leveraging CDS Hook events to detect advanced imaging orders at the point of clinician entry. For fertility-specific imaging, our platform automatically identifies the correct payer and RBM destination, such as eviCore or NIA Magellan, and initiates an automated submission. We incorporate pre-submission checks against ACR Appropriateness Criteria, offering alternative imaging recommendations to clinicians for orders that may not meet initial thresholds, thereby proactively reducing denials and peer-to-peer volume.

Key Benefits for Reproductive Endocrinology Practices

• Automated detection of PA-required fertility imaging orders at the point of care.
• Elimination of vendor identification errors through intelligent routing to RBMs like eviCore and NIA Magellan.
• Pre-submission appropriateness checks to reduce denials and avoid treatment delays.
• Streamlined submission of clinical documentation for pelvic MRIs and other advanced imaging.
• Accelerated patient progression through fertility treatment cycles by reducing PA backlog.
• Integrated workflow for managing peer-to-peer discussions for clinical denials.

Standards and Compliance for Fertility Imaging PA

Klivira's platform adheres to industry standards, including Da Vinci CRD for coverage requirements discovery and Da Vinci PAS for conformant payer submissions. We utilize X12 278 for electronic data interchange with payers and vendors, ensuring secure and standardized communication of protected health information (PHI) in accordance with HIPAA. Our integration with ACR Appropriateness Criteria ensures alignment with widely accepted medical necessity frameworks for imaging.