Automating Imaging Prior Auth for Advanced Radiology

The Manual Burden of Imaging Prior Auth

Without automation, the typical imaging prior auth workflow involves multiple manual steps, from identifying PA requirements to navigating various vendor portals. Clinicians order advanced imaging, and staff must manually check for PA requirements, identify the correct radiology benefit manager (RBM) like eviCore, NIA Magellan, or Carelon Medical Benefits Management (formerly AIM Specialty Health), and submit documentation through separate portals. This fragmented process is a primary driver of administrative overhead and patient access delays.

Common Failure Modes in Manual Imaging PA

• **Vendor Identification Errors:** Incorrect RBM portal used or failure to identify an RBM when one is required, leading to delayed or denied requests.
• **ACR Appropriateness Gaps:** Clinical documentation not meeting ACR Appropriateness Criteria thresholds, resulting in denials or recommendations for alternative imaging [src: acr-appropriateness].
• **High Peer-to-Peer Volume:** Frequent clinical denials on appropriateness grounds often necessitate time-consuming peer-to-peer discussions with RBM medical directors.
• **Imaging Scheduling Delays:** PA backlogs directly impact patient throughput, delaying access to critical advanced imaging slots.
• **Missed PA Requirements:** Failure to detect PA requirements at the point of order entry can lead to retrospective denials or rescheduled appointments.

Klivira's Automated Imaging Prior Auth Workflow

Klivira transforms imaging prior auth through intelligent automation. Our platform integrates directly with your EMR to detect advanced imaging orders at the point of care via CDS Hooks. It then automatically identifies the correct payer or RBM (e.g., eviCore, NIA Magellan, Carelon Medical Benefits Management) and routes the submission, ensuring compliance with established medical necessity frameworks like ACR Appropriateness Criteria [src: acr-appropriateness].

Key Benefits of Klivira for Imaging Prior Auth

• **Real-time PA Detection:** EMR-side detection at order entry ensures no imaging PA is missed, leveraging Da Vinci CRD capabilities [src: davinci-crd-ig].
• **Automated RBM Routing:** Klivira intelligently routes submissions to the correct destination, whether payer-direct or to RBMs like eviCore, NIA Magellan, or Carelon Medical Benefits Management.
• **Pre-submission Appropriateness Checks:** Evaluate orders against ACR Appropriateness Criteria before submission, surfacing alternative imaging recommendations to clinicians at order entry [src: acr-appropriateness].
• **Reduced Peer-to-Peer Friction:** Automated workflows streamline the process for clinical denials, routing them efficiently for peer-to-peer discussions.
• **Accelerated Imaging Schedules:** Automation significantly reduces PA cycle times, minimizing delays and improving patient access to critical advanced imaging.

Industry Standards and Frameworks for Imaging PA

Klivira's imaging prior auth solution is built upon robust industry standards. We leverage HL7 FHIR Da Vinci CRD for coverage requirements discovery [src: davinci-crd-ig] and Da Vinci PAS for automated payer submissions [src: davinci-pas-ig]. Submissions also utilize X12 278 for EDI transactions. Crucially, our platform incorporates the ACR Appropriateness Criteria as the dominant medical-necessity framework for evaluating advanced imaging requests across major commercial and government payers [src: acr-appropriateness].

Klivira's Differentiated Approach to Imaging Prior Auth

Klivira's platform provides a comprehensive solution for imaging prior auth, distinctively integrating RBM routing, ACR Appropriateness Criteria-aware pre-submission checks, and alternative-imaging recommendations at the point of order entry. This proactive approach minimizes denials and administrative burden. While Klivira cannot dictate RBM review times or clinician availability for peer-to-peers, our automation drastically reduces the upstream friction and improves the overall efficiency of the imaging PA process, a substantial portion of medical-PA transaction volume [src: caqh-index].