Accelerating Pediatric Oncology Imaging Prior Auth for Childhood Cancer Care

The Criticality of Imaging Prior Authorization in Pediatric Oncology

Pediatric oncology patients require timely, precise advanced imaging for accurate diagnosis, staging, and monitoring of treatment response, including during chemotherapy regimens, CAR-T therapies, and proton beam therapy. Delays in securing prior authorizations for these vital scans can disrupt treatment protocols and cause undue stress for families. Klivira addresses these challenges by automating the PA process, ensuring rapid access to necessary diagnostics.

Key Imaging Modalities Requiring Prior Authorization

• MRI: Essential for evaluating brain, spine, and soft tissue tumors, often requiring specific sequences for pediatric cases.
• CT Scans: Utilized for chest, abdomen, and pelvis imaging to assess solid tumors and metastatic disease.
• PET Scans: Critical for initial staging, restaging, and assessing treatment response in various childhood cancers.
• Nuclear Medicine Scans: Including bone scans for metastasis and MIBG scans for neuroblastoma, often with specialized protocols.
• Advanced Ultrasound: For real-time assessment and guidance, particularly in abdominal and superficial lesions.

Navigating Radiology Benefit Managers (RBMs) for Pediatric Imaging

Many commercial payers route advanced imaging prior authorizations through specialized radiology benefit managers (RBMs) such as eviCore, NIA Magellan, and Carelon Medical Benefits Management (formerly AIM Specialty Health). Identifying the correct RBM and navigating their specific provider portals and medical necessity criteria, often based on ACR Appropriateness Criteria, adds significant complexity and potential for error in pediatric oncology workflows. Klivira automates this routing and submission.

Klivira's Automated Workflow for Pediatric Oncology Imaging PA

• EMR-side detection at order entry via CDS Hooks for advanced imaging ServiceRequests.
• Automated routing to the correct PA destination: payer-direct, Da Vinci PAS endpoints, or RBMs (eviCore, NIA Magellan, Carelon).
• Pre-submission evaluation against ACR Appropriateness Criteria to proactively identify potential denials.
• Proactive alternative-imaging recommendations surfaced to clinicians at order entry.
• Automated submission of X12 278 or portal data, populated directly from FHIR data.
• Integrated peer-to-peer scheduling for clinical denials, streamlining the appeal process.

Enhancing Clinical Appropriateness and Reducing Denials

Klivira's platform incorporates pre-submission checks against the widely accepted ACR Appropriateness Criteria, ensuring that imaging orders meet medical necessity guidelines before they are sent to payers or RBMs. This proactive approach helps pediatric oncology teams reduce clinical denials, minimize the need for time-consuming peer-to-peer reviews, and ensure that the most appropriate imaging studies are ordered for young patients.

Seamless EMR Integration for Pediatric Oncology Workflows

Our platform integrates deeply with your existing EMR system using industry standards like SMART on FHIR, Da Vinci CRD, and Da Vinci PAS. This connectivity enables real-time PA requirement detection at the point of order entry and automated extraction of critical clinical documentation—such as ICD-10 diagnoses, prior imaging history, and symptom details—directly from the EMR. This eliminates manual data entry and provides PA status updates within the clinician's workflow.

Operational Impact for Pediatric Oncology Departments

• Significantly reduced imaging scheduling delays for critical diagnostic procedures.
• Lower administrative burden and reduced manual effort for prior authorization coordinators.
• Fewer clinical denials and a streamlined process for peer-to-peer conversations.
• Improved compliance with payer and RBM documentation requirements.
• Enhanced patient experience through faster access to vital diagnostic imaging.