Streamlining Infectious Disease Imaging Prior Auth

Klivira automates the complex workflow of **infectious disease imaging prior auth**, ensuring timely access to critical diagnostic imaging for patients with complex conditions.

For revenue cycle directors and prior authorization coordinators in infectious disease practices, managing imaging prior authorizations is a significant operational burden. The manual process often leads to delays in diagnosis and treatment for conditions requiring advanced imaging, impacting patient outcomes and staff efficiency. Klivira provides a purpose-built solution to address these challenges.

The Critical Role of Imaging in Infectious Disease Management

Infectious disease specialists rely on advanced imaging, such as MRI, CT, and PET scans, to accurately diagnose conditions like osteomyelitis, deep-seated abscesses, endocarditis, and to monitor treatment response for complex regimens including OPAT and HIV therapies. Ensuring timely access to these diagnostics is paramount for effective antimicrobial stewardship and patient care, complementing PA for high-cost antivirals and antifungals.

Common ID Scenarios Requiring Imaging Prior Authorization

Evaluating bone and joint infections (e.g., osteomyelitis, septic arthritis).
Locating deep-seated abscesses or fluid collections.
Assessing cardiac involvement in endocarditis or myocarditis.
Monitoring treatment efficacy for chronic infections, including HIV and HCV.
Diagnosing central nervous system infections.
Pre-procedural imaging for complex OPAT access.

Navigating Radiology Benefit Managers for ID Imaging PA

Many advanced imaging requests for infectious disease patients are routed through specialized radiology benefit managers (RBMs) such as eviCore, NIA Magellan, and AIM Specialty Health (now Carelon Medical Benefits Management). These entities apply rigorous medical necessity criteria, often leading to complex submission processes and frequent peer-to-peer discussions, creating bottlenecks in the ID care pathway.

Klivira's Automated Workflow for Infectious Disease Imaging PA

**EMR-Side Detection:** Klivira identifies advanced imaging orders at the point of clinician entry via CDS Hook events, preventing missed PA requirements.
**Intelligent Routing:** Automatically determines the correct PA destination, whether payer-direct, an RBM like eviCore or NIA Magellan, or a Da Vinci PAS endpoint.
**ACR Appropriateness Check:** Pre-screens orders against ACR Appropriateness Criteria, providing alternative recommendations before submission to reduce denials.
**Automated Submission:** Populates all required fields from FHIR data for seamless submission to the correct portal or endpoint.
**Integrated Response Handling:** Manages approvals for automatic scheduling and routes modifications or denials to an integrated peer-to-peer workflow.

Addressing Key Challenges in ID Imaging Prior Authorization

Klivira directly tackles common failure modes in infectious disease imaging prior authorization. This includes eliminating missed PA requirements through EMR integration, ensuring accurate routing to the correct RBM or payer, and proactively identifying orders that may not meet appropriateness criteria, thereby reducing post-submission denials and the volume of peer-to-peer calls.

Standards-Based Approach to ID Imaging PA

Klivira leverages industry standards to optimize the infectious disease imaging prior authorization process. This includes using Da Vinci CRD for coverage requirements discovery, Da Vinci PAS for conformant payer submissions, and X12 278 for EDI submissions. The platform also integrates ACR Appropriateness Criteria as the dominant medical-necessity framework for imaging, ensuring clinical alignment.

Frequently asked questions

How does Klivira handle specific RBMs like eviCore or NIA Magellan for ID imaging?

Klivira's platform includes pre-built integrations and intelligent routing logic to automatically identify and submit to the correct RBM portal, such as eviCore, NIA Magellan, or Carelon Medical Benefits Management (formerly AIM Specialty Health), based on the payer and member plan for infectious disease imaging orders.

Can Klivira integrate with our EMR to detect ID imaging orders?

Yes, Klivira integrates with major EMR systems using SMART on FHIR and CDS Hooks, enabling real-time detection of advanced imaging orders for infectious disease patients at the point of order entry. This proactive approach ensures no PA is missed, improving efficiency for your prior authorization coordinators.

How does Klivira improve turnaround times for ID imaging PAs?

By automating PA requirement detection, intelligent routing, pre-submission appropriateness checks, and data population from the EMR, Klivira significantly reduces the manual effort and associated delays, accelerating the prior authorization cycle for infectious disease imaging and improving patient throughput.

What role do ACR Appropriateness Criteria play in ID imaging approvals?

Klivira incorporates ACR Appropriateness Criteria to evaluate infectious disease imaging orders pre-submission. This allows for proactive identification of orders that may not meet medical necessity, offering clinicians alternative imaging recommendations before a potential denial from the RBM or payer, aligning with clinical evidence.

Does Klivira support peer-to-peer scheduling for ID imaging denials?

Yes, for infectious disease imaging orders that result in a clinical denial, Klivira's platform provides an integrated workflow for scheduling and managing peer-to-peer discussions with RBMs or payers, streamlining this critical step in the appeals process and reducing administrative burden.