Klivira
Request demo

Optimizing Fertility (REI) Prior Authorization Automation

Klivira delivers end-to-end fertility (REI) prior authorization automation, specifically engineered to manage the complexities of reproductive health procedures and high-cost specialty medications.

For revenue cycle directors and prior authorization coordinators in fertility clinics, managing the volume and specificity of PA requests for IVF cycles, specialty drugs, and preservation procedures is a significant operational challenge. Manual processes lead to delays, denials, and clinician burden. Klivira's platform integrates directly with your EMR to transform this workflow, ensuring timely approvals and reducing administrative overhead.

The Unique PA Challenges in Fertility (REI)

Fertility (REI) practices face distinct prior authorization hurdles due to the high-cost nature and clinical complexity of treatments. Key PA categories include IVF cycles, IUI cycles, fertility-preservation procedures, and a range of specialty drugs critical to treatment protocols. These often require extensive clinical documentation and adherence to specific payer medical policies, leading to significant administrative time spent on manual processes.

High-Volume Prior Authorization Triggers in Fertility

  • In Vitro Fertilization (IVF) cycles, including associated laboratory services and embryo transfers.
  • Intrauterine Insemination (IUI) cycles.
  • Fertility preservation procedures, such as oocyte or embryo cryopreservation.
  • High-cost fertility specialty drugs (e.g., gonadotropins, GnRH antagonists/agonists).
  • Advanced diagnostic imaging and genetic testing related to infertility workups.

Klivira's Automated Workflow for Fertility PA

Klivira's platform integrates seamlessly into your existing EMR, leveraging SMART on FHIR and CDS Hooks to detect PA requirements at the point of order entry for fertility treatments and medications. This proactive approach eliminates missed PA-required orders, a common failure mode in manual workflows, and initiates the automation process immediately, directly impacting patient care pathways.

Streamlined Documentation and Payer Connectivity

Our system automatically assembles comprehensive documentation packets by reading FHIR resources from your EMR, including ServiceRequest, MedicationRequest, and DocumentReference. Klivira then routes these packets through the most efficient payer channel—prioritizing Da Vinci PAS APIs, X12 278 via clearinghouse, or provider portal APIs—ensuring payer-specific submission for commercial and managed care plans relevant to fertility services.

Real-time Status Tracking and Denial Management

Klivira provides real-time status updates by polling payer endpoints or receiving webhooks, normalizing decision-time variance and surfacing status changes directly to PA coordinators and ordering clinicians within the EMR. For denials, the platform parses reasons (e.g., X12 CARC/RARC codes) and automates appeal packet assembly, tracking timely-filing windows to minimize lost revenue for fertility services.

Operational Benefits for Fertility (REI) Practices

By automating fertility prior authorizations, Klivira helps reduce administrative burden, accelerate treatment initiation, and improve financial outcomes. Our system addresses critical failure modes such as documentation gaps, lost-to-follow-up appeals, and channel-selection errors, allowing your team to focus on patient care rather than manual paperwork. This operational efficiency is critical for high-volume, high-value services like IVF.

Frequently asked questions

How does Klivira handle PA for specific fertility drugs?

Klivira's payer policy engine incorporates rules for fertility specialty drugs, sourcing from published medical policies (e.g., Aetna CPBs, UHC Medical Policy Library). Our system identifies PA requirements for specific medications at order entry and assembles the necessary documentation for submission via the appropriate channel, including NCPDP SCRIPT for pharmacy benefits or X12 278 for medical benefits.

Can Klivira integrate with our EMR for fertility orders?

Yes, Klivira offers robust EMR integration, including SMART App Launch on FHIR for platforms like Epic, Cerner / Oracle Health, athenahealth, MEDITECH Expanse, and eClinicalWorks. We utilize CDS Hooks for real-time PA requirement detection when a clinician places an order for fertility procedures or medications, ensuring seamless workflow integration.

What happens if a fertility PA is denied?

Upon denial, Klivira parses the denial reason (e.g., X12 CARC/RARC codes) and routes the case for appropriate action. This can include auto-appeal when additional documentation can be assembled, human review for clinical necessity judgments, or peer-to-peer scheduling. Our system also tracks timely-filing windows to ensure appeals are submitted promptly.

Does Klivira support Da Vinci standards for fertility PAs?

Absolutely. Klivira's platform leverages Da Vinci CRD for coverage requirement discovery at order entry, Da Vinci DTR for automated documentation assembly where supported by payers, and Da Vinci PAS for electronic prior authorization submission to payers in production conformance. This ensures adherence to industry standards for efficient ePA.

How does Klivira ensure the authorization number is linked to the claim?

Upon approval, Klivira automatically writes the authorization number back to the EMR. This is typically achieved via a FHIR DocumentReference write or an order-update mechanism, ensuring that the authorization number is accurately recorded in the order record for downstream claim submission, preventing denials due to missing authorization data.

Related coverage

Other fertility-reproductive prior auth workflows

Ready to automate this workflow for this specialty?

See how Klivira automates prior authorizations for your team.

Request a demo