Transforming Oncology Prior Authorization with Epic Orchestrate

Navigating the complexities of prior authorization in cancer care demands integrated solutions. Klivira enhances **oncology Epic Orchestrate** workflows, embedding automation directly into your clinical and revenue cycle operations.

Oncology prior authorization is among the most intricate and high-volume segments in healthcare, characterized by high-cost biologics, frequent regimen changes, and critical treatment timelines. Revenue cycle leaders and prior authorization coordinators face immense pressure to accelerate approvals while maintaining compliance. Integrating specialized automation within your Epic environment is essential to meet these demands.

The Unique Challenges of Oncology Prior Authorization

Oncology PA is distinct due to the volume and complexity of high-cost treatments like chemotherapy regimens, biologics, and radiation therapy. A single patient often requires dozens of PA events from diagnosis through surveillance, each demanding precise documentation and rapid turnaround to prevent treatment delays that can impact patient outcomes.

Critical Prior Authorization Triggers in Oncology

HCPCS J-code chemotherapy and biologic infusions (e.g., immunotherapies, targeted therapies, antibody-drug conjugates)
Advanced imaging for staging and surveillance (PET/CT, advanced MRI, tumor-specific molecular imaging)
Radiation oncology procedures (IMRT, IGRT, SBRT, brachytherapy, proton-beam therapy CPT ranges)
Genetic and molecular testing (NGS panels, single-gene tests) for treatment selection and risk stratification
High-volume supportive care medications (growth factors, antiemetics, bone-targeting agents)

Leveraging Epic Orchestrate for Oncology PA Efficiency

Epic Orchestrate offers an Epic-native workflow surface, enabling the integration of SMART on FHIR applications directly into clinical workflows. Klivira leverages this capability to embed NCCN-compendium-aware policy logic and automation at the point of order entry, guiding users through documentation requirements and initiating PA submissions seamlessly within your existing Epic environment.

Streamlining Documentation and Reducing Denials

Automated surfacing of NCCN Clinical Practice Guidelines requirements for diagnosis confirmation and treatment rationale.
Guided data capture for molecular markers (e.g., ER/PR/HER2, EGFR/ALK/PD-L1) and performance status (ECOG, Karnofsky).
Proactive identification of potential step therapy conflicts or off-label use without NCCN Compendium support.
Facilitated collection of prior-line treatment response and rationale for regimen changes.
Support for specific radiation oncology documentation, including prescribed dose, fractionation, and target volume rationale.

Klivira's Specialized Approach for Oncology Workflows

Klivira's platform is engineered to handle the unique cadence of oncology PA, including regimen-level approvals and the frequent need for new PAs due to toxicity, progression, or treatment changes. Our system distinguishes between medical and pharmacy benefit drugs, routing oral oncolytics through PBM channels and infusions via X12 278, all while maintaining concurrent PA tracking for a patient's entire treatment course.

Integrating with Epic for Comprehensive Prior Authorization

By integrating with Epic via SMART on FHIR, Klivira ensures that prior authorization tasks are not siloed but are an intrinsic part of the care continuum. This integration supports start-of-treatment urgency, minimizes manual data entry, and provides real-time status updates directly within the Epic Orchestrate environment, empowering prior authorization coordinators and clinical staff to focus on patient care.

Frequently asked questions

How does Klivira handle the distinction between medical and pharmacy benefit drugs for oncology PAs within Epic Orchestrate?

Klivira's logic automatically identifies whether an oncology drug falls under medical (J-codes, infusions) or pharmacy (oral oncolytics) benefit. It then routes the PA request through the appropriate channel – X12 278 or payer portals for medical, and ePA partners like CoverMyMeds or Surescripts for pharmacy benefit – all while tracking the status within your Epic Orchestrate workflow.

Can Klivira help with PAs for off-label oncology drug use?

Yes, Klivira's NCCN-compendium-aware policy logic specifically supports off-label use requests. It guides the collection of necessary documentation, such as the NCCN Compendium category (1, 2A, 2B), and helps identify if the requested indication aligns with payer acceptance criteria, flagging potential issues before submission to mitigate denials.

How does Klivira address the high volume of PA events per oncology patient?

Klivira provides concurrent PA tracking, managing dozens of PA events per patient across diagnosis, staging, treatment initiation, regimen changes, supportive care, and surveillance imaging. This regimen-level PA workflow bundles related components where possible and ensures all PAs are tracked centrally within your Epic environment, providing a holistic view of authorization status.

What role does Epic Orchestrate play in optimizing peer-to-peer reviews for oncology denials?

While Klivira automates the initial PA submission and appeal preparation, Epic Orchestrate can surface prompts and scheduling integrations for peer-to-peer reviews. Klivira's platform helps identify clinical-necessity denials and can facilitate the scheduling process for oncologists to engage with payer medical directors, reducing delays in this critical step of the PA lifecycle.

How does Klivira integrate NCCN guidelines into the Epic Orchestrate workflow for oncology?

Klivira's integration with Epic Orchestrate surfaces NCCN-compendium-aware policy logic directly at the point of order entry. This means that as an oncologist orders a regimen, the system prompts for specific documentation (e.g., molecular markers, prior-line therapy, performance status) required by NCCN guidelines and common payer policies, ensuring comprehensive and compliant submissions.