Streamlining Gastroenterology Prior Authorizations with Epic Orchestrate

Klivira optimizes gastroenterology prior authorizations by integrating directly with Epic Orchestrate, embedding automation into your native EMR workflows for high-volume GI treatments and procedures.

Gastroenterology practices face a significant prior authorization burden, particularly with chronic biologics, advanced imaging, and specialty procedures. Manual processes within Epic can impede patient access and strain revenue cycle operations. Klivira leverages Epic Orchestrate to transform this challenge into a streamlined, automated workflow, directly within the clinician's and coordinator's native environment.

The High-Volume PA Landscape in Gastroenterology

Gastroenterology prior authorizations are characterized by high volume and clinical complexity, especially for chronic conditions like Inflammatory Bowel Disease (IBD) and Hepatitis C. Key PA triggers include biologics such as Humira, Stelara, Skyrizi, and Entyvio, along with advanced imaging like MR enterography and specific endoscopic procedures like capsule endoscopy (CPT 91110).

Critical Prior Authorization Triggers in GI Workflows

**IBD Biologics:** TNF inhibitors (adalimumab, infliximab), integrin inhibitors (vedolizumab), IL-12/23 inhibitors (ustekinumab), JAK inhibitors (tofacitinib, upadacitinib), S1P modulators (ozanimod, etrasimod), and risankizumab for Crohn's.
**Hepatitis C Direct-Acting Antivirals (DAAs):** Sofosbuvir-velpatasvir (Epclusa) and glecaprevir-pibrentasvir (Mavyret), requiring specific genotype and fibrosis staging documentation.
**Advanced Imaging:** MRCP, MR enterography, and CT enterography for IBD assessment and other abdominal diagnostics.
**Endoscopic Procedures:** Capsule endoscopy, ERCP, and EUS for diagnostic and therapeutic indications.
**Specialty Functional GI Drugs:** Eluxadoline (Viberzi), prucalopride (Motegrity), linaclotide (Linzess), and plecanatide (Trulance).

Integrating GI PA Automation with Epic Orchestrate

Epic Orchestrate provides an Epic-native workflow surface for embedding SMART on FHIR applications, enabling seamless integration of prior authorization automation directly into the EMR. Klivira leverages this capability to bring intelligent PA workflows for gastroenterology into the Epic Hyperdrive environment, reducing context switching and improving data flow between clinical documentation and authorization requests.

Key Documentation Requirements for GI Prior Authorizations

**IBD Biologics:** Diagnosis confirmation, disease severity assessment (Mayo score for UC, CDAI for Crohn's), prior conventional and biologic therapy trials, TB/hepatitis screening, and step therapy compliance per ACG/AGA guidelines.
**Hep C DAAs:** Genotype, fibrosis stage (FibroSure, transient elastography), prior-treatment history, and drug-drug interaction review.
**Advanced Imaging:** Clinical question, prior imaging history, and completion of conservative evaluation workup.
**Capsule Endoscopy:** Prior workup including upper GI series or EGD, and specific indication meeting payer medical necessity criteria.

Klivira's Approach to Gastroenterology PA within Epic Orchestrate

Klivira's platform, integrated via Epic Orchestrate, automates the complex decision logic required for GI prior authorizations. This includes ACG/AGA-guideline-aware step therapy logic for IBD biologics, automated treatment-status classification from EMR medication history, and specialized workflows for Hep C DAAs that incorporate genotype and fibrosis stage data. The system also manages periodic re-authorization for chronic treatments and routes based on medical-vs-pharmacy benefit splits.

Frequently asked questions

How does Klivira handle the medical vs. pharmacy benefit split for GI biologics in Epic Orchestrate?

Klivira’s integration with Epic Orchestrate automatically identifies and routes prior authorization requests based on whether a biologic is administered via medical benefit (provider-administered infusion) or pharmacy benefit (self-administered injection). This ensures the correct payer channel is engaged, even when the same agent for the same patient may switch benefit sides over time.

Can Klivira automate re-authorizations for chronic IBD treatments within Epic Orchestrate?

Yes, Klivira's platform supports periodic re-authorization workflows for chronic IBD biologic treatments. Integrated with Epic Orchestrate, it can proactively flag upcoming re-authorization needs and guide the collection of continuous documentation of disease response, streamlining this ongoing PA burden for gastroenterology practices.

What specific GI guidelines does Klivira incorporate into its PA logic?

Klivira’s prior authorization logic for gastroenterology incorporates guidelines from leading bodies such as the American College of Gastroenterology (ACG), American Gastroenterological Association (AGA), and American Association for the Study of Liver Diseases (AASLD). This ensures that step therapy protocols, documentation requirements, and medical necessity criteria align with established clinical evidence.

How does Klivira's Epic Orchestrate integration improve documentation for Hep C DAAs?

For Hepatitis C DAAs, Klivira’s integration with Epic Orchestrate streamlines the collection of critical documentation such as genotype, fibrosis stage (e.g., FibroSure, transient elastography), and prior-treatment history directly from the EMR. This automation helps prevent common denial reasons related to missing or insufficient documentation for these high-cost therapies.

Does Klivira support biosimilar step therapy requirements for GI biologics?

Yes, Klivira’s payer-policy logic, delivered through Epic Orchestrate, is designed to account for payer-specific biosimilar mandates and step therapy requirements for GI biologics. The system helps ensure compliance with policies that may require failure of conventional therapy, trial of biosimilars before brand biologics, or specific sequencing of TNF vs. non-TNF agents.