Psychiatry Epic Orchestrate: Automating Prior Authorization Workflows

Klivira streamlines complex prior authorization processes for psychiatry within Epic Orchestrate, embedding automation directly into your clinical and revenue cycle workflows. This integration ensures efficient management of high-volume PA categories, from specialty medications to intensive outpatient programs.

Prior authorization for behavioral health services and medications presents unique challenges, marked by time-sensitive admissions, continuous concurrent reviews, and intricate documentation requirements. Revenue cycle directors and prior authorization coordinators face increasing pressure to manage these complexities while ensuring compliance and patient access. Klivira addresses these hurdles by integrating directly into your Epic environment, transforming prior authorization from a manual burden into an automated, data-driven process.

Integrating Psychiatry PA into Epic Orchestrate

The demands of psychiatry prior authorization, encompassing everything from inpatient admissions to specialty medications like atypical antipsychotics and esketamine, require a deeply integrated solution. Klivira leverages Epic Orchestrate as a native workflow surface, embedding PA automation directly where clinicians and staff work. This approach ensures that critical PA steps are initiated and managed proactively, reducing administrative overhead and accelerating patient access to care.

High-Volume Prior Authorization Triggers in Behavioral Health

Inpatient psychiatric admissions and continued stays, including SUD admissions requiring ASAM criteria.
Partial Hospitalization (PHP) and Intensive Outpatient (IOP) programs.
Residential treatment for substance use disorder and eating disorders.
Specialty psychiatric medications: long-acting injectables (e.g., paliperidone palmitate), esketamine (Spravato), brexanolone (Zulresso), zuranolone (Zurzuvae), and tardive dyskinesia drugs (e.g., valbenazine).
Transcranial Magnetic Stimulation (TMS) and Electroconvulsive Therapy (ECT).
Ketamine and esketamine clinic services, often with FDA label-specific PA paths.

Streamlining Documentation for Psychiatry PA in Epic

Effective psychiatry prior authorization relies heavily on precise clinical documentation, often guided by frameworks like the APA Practice Guidelines and ASAM Criteria. Klivira's integration with Epic Orchestrate ensures that necessary data points—such as DSM-5-TR diagnoses, severity scales (PHQ-9, GAD-7), safety risk assessments, and prior level-of-care trials—are automatically extracted or prompted. This reduces manual chart review and ensures fidelity to payer-specific requirements for treatments like TMS (failed antidepressant trials) or specialty injectables.

Mitigating Common Psychiatry PA Denials

ASAM level mismatch, where documented severity does not align with requested level of care.
Step therapy requirements, particularly for TMS (insufficient antidepressant trials) or specialty injectables (lack of oral medication trial).
Concurrent review denials for continued inpatient or residential stays when severity criteria are no longer met.
Potential Mental Health Parity and Addiction Equity Act (MHPAEA) violations, where payer criteria may be more restrictive than comparable medical-surgical benefits.
Challenges with out-of-network treatment, especially for residential SUD care where in-network options are limited.

Klivira's Differentiated Approach for Psychiatry within Epic Orchestrate

Klivira's platform provides specialized capabilities tailored for the unique demands of psychiatry PA, seamlessly integrated into Epic Orchestrate. This includes ASAM-criteria-aware level-of-care logic for SUD, automated flagging of potential parity issues, and a robust workflow for continuous concurrent review of inpatient and residential stays. By automating the evidence submission for treatments like TMS step-therapy, Klivira empowers your team to manage complex cases more efficiently and reduce unwarranted denials.

Frequently asked questions

How does Klivira handle time-sensitive psychiatric admissions within Epic Orchestrate?

Klivira integrates directly into Epic Orchestrate to streamline the expedited authorization process for psychiatric and SUD emergencies. Our system can pre-populate critical patient data and submit urgent requests through appropriate payer channels, ensuring rapid decision-making for time-sensitive admissions and continued-stay reviews.

Can Klivira automate documentation for TMS prior authorizations in Epic?

Yes, Klivira automates the collection and submission of documentation required for TMS prior authorizations. Within Epic Orchestrate, our platform identifies and compiles evidence of failed antidepressant trials, ensuring compliance with payer step-therapy requirements and reducing manual effort for your PA coordinators.

How does Klivira support compliance with ASAM Criteria for SUD treatment in Epic?

Klivira incorporates ASAM-criteria-aware logic into its platform, guiding documentation and submission for substance use disorder treatment within Epic. This helps ensure that the submitted authorization requests align with ASAM dimensions, reducing denials related to level-of-care mismatch and supporting appropriate care placement.

Does Klivira's Epic Orchestrate integration address specialty psychiatric medications?

Absolutely. Klivira manages prior authorizations for a wide range of specialty psychiatric medications, including long-acting injectables, esketamine, and drugs for tardive dyskinesia. Our Epic Orchestrate integration automates the submission of diagnosis confirmation, prior oral-medication trials, and REMS documentation where applicable.

How does Klivira assist with Mental Health Parity Act considerations?

Klivira's policy engine is designed to flag potential parity issues by analyzing payer criteria against comparable medical-surgical benefits. This feature, integrated into your Epic Orchestrate workflow, provides an additional layer of oversight to ensure compliance with MHPAEA and advocate for appropriate patient access to behavioral health services.