Optimizing Pulmonology Prior Authorization Automation

Klivira's pulmonology prior authorization automation platform streamlines the complex process of securing approvals for high-cost therapies and essential services, integrating directly into your existing EMR workflows.

For revenue cycle directors and prior authorization coordinators in pulmonology, managing PA for biologics, home oxygen, and advanced diagnostics presents significant administrative challenges. Manual processes lead to delays, denials, and clinician burnout. Klivira transforms this landscape by automating key steps, ensuring compliance and efficiency.

The Unique Prior Authorization Demands of Pulmonology

Pulmonology practices navigate a distinct set of prior authorization triggers, from high-cost specialty medications for severe asthma and idiopathic pulmonary fibrosis (IPF) to durable medical equipment like home oxygen and BiPAP. These require detailed clinical documentation, often against specific payer criteria and clinical guidelines such as ATS, GOLD, and GINA.

Common Pulmonology PA Triggers

Asthma biologics (e.g., Dupixent, Nucala, Fasenra, Tezspire, Xolair)
Home oxygen, BiPAP, and CPAP
Pulmonary function testing (PFTs)
IPF antifibrotics (e.g., Esbriet, Ofev)
COPD specialty drugs and advanced inhalers (e.g., Ohtuvayre, Trelegy, Breztri)
Lung transplant evaluation and immunosuppression

Klivira's Automated Workflow for Pulmonology PA

Klivira's platform integrates with your EMR to detect prior authorization requirements at the point of order entry, leveraging CDS Hooks and Da Vinci CRD-style capabilities. This proactive identification prevents missed authorizations, a common failure mode in manual workflows, ensuring all PA-required orders are captured immediately.

Evidence-Based Documentation and Submission

Our system automates the assembly of documentation by reading FHIR resources from the EMR, ensuring all required elements—such as eosinophil counts for asthma biologics or prior step-therapy records—are included. It aligns with guidelines like ATS, GOLD, and GINA, and routes submissions via Da Vinci PAS, X12 278, or payer portals, optimizing for the fastest electronic channel.

Streamlined Denial Management and Appeals

Denials for pulmonology services often stem from step-therapy requirements or unmet clinical thresholds. Klivira automates the parsing of denial reasons and facilitates appeal preparation, tracking timely-filing windows to prevent lost revenue. For complex clinical-necessity denials, it efficiently routes cases for human review or peer-to-peer scheduling.

EMR Integration and Payer Connectivity

Klivira offers robust integration with leading EMRs including Epic, Cerner / Oracle Health, athenahealth, MEDITECH Expanse, eClinicalWorks, and Veradigm via SMART App Launch on FHIR and other standard interfaces. Our payer policy engine connects to major commercial and government payers, ingesting medical policies from sources like Aetna CPBs and UHC Medical Policy Library to inform authorization logic.

Frequently asked questions

How does Klivira handle specific documentation for asthma biologics?

Klivira's system is designed to identify and extract specific data points from the EMR, such as eosinophil counts, prior controller therapy history, and exacerbation records, as required by payer policies and clinical guidelines like GINA. This ensures comprehensive, evidence-based documentation for asthma biologic prior authorizations.

Can Klivira automate prior authorizations for durable medical equipment (DME) like home oxygen?

Yes, Klivira automates PA for DME common in pulmonology, including home oxygen, BiPAP, and CPAP. The system identifies the requirement at order entry, assembles necessary clinical justification from the EMR, and submits through the appropriate payer channel, tracking status until approval.

What role do clinical guidelines like ATS or GOLD play in Klivira's automation?

Klivira's payer policy engine incorporates logic derived from major clinical guidelines such as ATS, GOLD for COPD, and GINA for asthma. This ensures that automated step-therapy checks and documentation requirements align with recognized clinical standards, improving approval rates and compliance.

How does Klivira address step-therapy denials common in pulmonology?

Klivira's system proactively identifies step-therapy requirements at the point of order entry. If a denial occurs due to unmet step-therapy, the platform helps auto-assemble an appeal packet with documentation of prior trials or clinical contraindications, facilitating a more efficient appeals process.

What EMR integrations does Klivira support for pulmonology practices?

Klivira integrates with major EMR systems used in pulmonology, including Epic, Cerner / Oracle Health, athenahealth, MEDITECH Expanse, eClinicalWorks, and Veradigm, leveraging SMART App Launch on FHIR, CDS Hooks, and HL7 v2 interfaces to ensure seamless data exchange and workflow integration.