Optimizing Rheumatology Prior Authorizations with Epic Orchestrate

Klivira streamlines **rheumatology Epic Orchestrate** workflows, automating prior authorizations for high-cost biologics and infusion therapies directly within the clinician's native Epic environment, enhancing efficiency and patient access.

Rheumatology practices face significant administrative burdens due to the chronic nature of conditions, complex step therapy protocols, and the high cost of advanced agents like biologics and JAK inhibitors. Integrating prior authorization (PA) automation directly into Epic Orchestrate provides a critical pathway to alleviate this burden, accelerate treatment initiation, and ensure compliance with payer requirements.

The Rheumatology PA Burden within Epic Orchestrate

Rheumatology prior authorizations are among the most complex and volume-intensive, particularly for biologic and targeted synthetic DMARDs. These high-cost medications, often prescribed for chronic conditions such as rheumatoid arthritis (RA), psoriatic arthritis (PsA), ankylosing spondylitis (AS), and lupus, frequently trigger PA requirements. Klivira's integration with Epic Orchestrate surfaces these critical PA tasks within the familiar Epic Hyperdrive interface, minimizing disruption to clinical workflows.

Key PA Triggers in Rheumatology Workflows

Biologics: TNF-alpha inhibitors (e.g., adalimumab, etanercept, infliximab) and non-TNF biologics (e.g., IL-6, IL-17, IL-23 inhibitors, B-cell depletion).
JAK Inhibitors: Targeted synthetic DMARDs (e.g., tofacitinib, baricitinib, upadacitinib).
Specialty Drugs: Agents for specific indications (e.g., anifrolumab for SLE, belimumab for SLE, ustekinumab).
Infusion Therapy: Provider-administered biologics and other IV medications.
Advanced Imaging: MRI for inflammatory arthritis assessment.
DEXA Scans: For osteoporosis management, particularly in chronic steroid patients.

Integrating Klivira with Epic Orchestrate for Rheumatology Workflows

Klivira leverages Epic's native workflow capabilities, including SMART on FHIR integration, to embed PA automation directly into the Epic Orchestrate environment. This allows rheumatology providers and PA coordinators to initiate, track, and manage prior authorizations without leaving the patient chart. The system automatically identifies PA requirements for ordered medications and services, streamlining the submission process and reducing manual data entry.

Addressing Complex Documentation Requirements

Diagnosis Documentation: Automation of ICD-10 codes with disease-specific criteria (e.g., 2010 ACR/EULAR for RA, CASPAR for PsA, modified New York/ASAS for AS, 2019 EULAR/ACR for SLE).
Disease Activity Assessment: Capturing and transmitting scores like DAS28, CDAI, SDAI for RA; PASI/BSA for psoriasis; BASDAI for AS; SLEDAI for SLE.
Prior Conventional DMARD Trial: Documenting methotrexate trial and response, or contraindications, as required by ACR Treatment Guidelines.
Step Therapy Compliance: Ensuring documentation of prior TNF inhibitor failure or specific biosimilar trials.
Screening Completion: Verification of TB, hepatitis B/C, and immunization status prior to immunosuppressive biologic initiation.

Automating Step Therapy and Biosimilar Logic

A significant challenge in rheumatology PA is navigating the variability in payer step therapy protocols and biosimilar substitution mandates. Klivira's platform, integrated with Epic Orchestrate, incorporates ACR-guideline-aware policy logic to guide users through appropriate sequencing. This includes distinguishing per-payer biosimilar mandates and managing brand-to-biosimilar conversion workflows, directly addressing common denial reasons such as 'step therapy not completed' or 'biosimilar substitution required'.

Enhanced Efficiency for Chronic Treatment Re-authorizations

Rheumatology patients often require ongoing biologic therapy, necessitating periodic re-authorizations every 6 or 12 months. Klivira's system within Epic Orchestrate automates the re-authorization workflow, prompting for continuous documentation of disease response and adherence to payer policies. This proactive management reduces the risk of treatment interruptions due to lapsed PAs and sustains patient access to critical therapies.

Frequently asked questions

How does Klivira handle biosimilar substitution within Epic Orchestrate for rheumatology?

Klivira integrates payer-specific policy logic to identify when biosimilar substitution is required or preferred. Within Epic Orchestrate, the system guides the user through the appropriate steps, ensuring documentation aligns with payer mandates for biosimilar trials before brand biologic approval, directly addressing common denial reasons.

What specific rheumatology documentation does Klivira automate for PA submissions?

Klivira automates the extraction and submission of critical rheumatology documentation, including diagnosis criteria (e.g., ACR/EULAR, CASPAR), disease activity scores (e.g., DAS28, PASI), evidence of prior conventional DMARD trials, and screening results (e.g., TB, hepatitis). This ensures comprehensive and compliant submissions per payer and ACR Treatment Guidelines.

Can Klivira manage both medical and pharmacy benefit PAs for rheumatology drugs?

Yes, Klivira's platform is designed to manage prior authorizations for rheumatology medications covered under both medical and pharmacy benefits. This is crucial for agents that may be self-administered (pharmacy benefit) or provider-administered via infusion (medical benefit), ensuring consistent PA processing regardless of the benefit pathway.

How does Klivira support periodic re-authorizations in rheumatology?

For chronic rheumatologic conditions requiring ongoing treatment, Klivira automates the periodic re-authorization process. The system tracks re-authorization due dates, prompts for necessary updated documentation (e.g., continued disease activity assessment), and streamlines the submission to ensure continuous patient access to approved biologics and other therapies.

Does Klivira's Epic Orchestrate integration support pediatric rheumatology PA requirements?

Yes, Klivira's platform includes capabilities for managing pediatric-specific PA flows, which can be integrated into Epic Orchestrate. This accounts for unique requirements such as weight-based dosing and adherence to pediatric rheumatology guideline criteria, adding a layer of specialized support for this patient population.