Streamlining Orthopedics Prior Authorization with Epic Orchestrate

The Orthopedics PA Burden in Epic Orchestrate

Orthopedic practices manage a high volume of prior authorizations for critical services, including MRI/advanced imaging, joint replacement, spine surgery, and DME. The complexity is amplified by multi-step PA cascades, where imaging approval often precedes surgical authorization. Leveraging Epic Orchestrate provides a native platform for enhancing these workflows, allowing for integrated automation that reduces manual intervention and accelerates patient care pathways.

Key Orthopedic PA Triggers & Documentation Requirements

• **Common Prior Authorization Triggers:** Major joint replacement (e.g., CPT 27447, 27130), spine surgery (e.g., CPT 22612, 22633), advanced imaging (MRI of spine and joints, CT), sports-medicine procedures (arthroscopy, ACL reconstruction), orthobiologics, and DME (braces, prosthetics).
• **Essential Documentation for Orthopedic PA:** Documentation of conservative-care trials (NSAIDs, physical therapy, injections, weight loss), BMI considerations for joint replacement, imaging confirmation of advanced joint disease (Kellgren-Lawrence grade) or structural pathology, correlation of imaging findings with symptoms, and neurological exam findings. These align with guidelines such as AAOS Clinical Practice Guidelines and ACR Appropriateness Criteria.

Klivira's Integration with Epic Orchestrate for Orthopedics

Klivira leverages Epic Orchestrate's native capabilities, including SMART on FHIR app placement, to embed prior authorization automation directly into the orthopedic workflow. Our platform utilizes AAOS-guideline-aware conservative-care logic to track trial durations and modalities, automates the extraction of BMI and imaging documentation from the EMR, and orchestrates multi-step PA cascades common in orthopedics, from imaging to surgery to DME. This ensures comprehensive data submission while minimizing staff effort.

Addressing Specialty-Specific Workflow Constraints

The high PA volume per orthopedic surgeon, coupled with pre-operative scheduling pressures, demands efficient solutions. Klivira, working within Epic Orchestrate, addresses these by intelligently routing imaging requests to specialty benefit-management vendors (e.g., Carelon MBM, eviCore successor vendors) when applicable, and by providing tools for managing peer-to-peer reviews for complex clinical-necessity denials. This integrated approach ensures that PA approvals keep pace with surgical scheduling, preventing costly delays.

Optimizing Payer & EMR Touchpoints

• **EMR Integration:** Klivira's SMART on FHIR integration with Epic enables automated data extraction for order types (imaging, surgical procedures, DME) and clinical templates, pulling vitals, problem lists, and imaging history directly.
• **Payer Connectivity:** The platform connects to diverse payer channels, including X12 278 transactions, ePA portals, and direct payer portals, ensuring submissions meet specific payer requirements for orthopedic procedures.
• **Guideline Adherence:** Automation supports documentation aligned with clinical guideline bodies like the AAOS and ACR, reducing denials related to insufficient conservative care or inappropriate imaging use.

Mitigating Common Orthopedic PA Denials

Automation within Epic Orchestrate helps orthopedic practices proactively address frequent denial reasons. Klivira ensures that conservative-care trial documentation is complete and adheres to payer duration requirements, mitigates issues related to BMI criteria for elective joint replacements, and confirms imaging-symptom correlation. By automating the submission of comprehensive, guideline-compliant data, the platform significantly reduces denials stemming from documentation gaps or inappropriate-use criteria for advanced imaging.