Achieve End-to-End Prior Authorization Automation

The Burden of Manual Prior Authorization Workflows

Traditional prior authorization workflows are characterized by manual checks, fragmented data, and significant administrative overhead. Clinicians often miss PA requirements at order entry, leading to delayed care or retrospective denials. PA coordinators navigate disparate payer portals, manually assemble documentation, and spend valuable time tracking statuses across varied channels (src: caqh-index).

Common Failure Modes Addressed by Automation

• Missed PA-required orders at detection, leading to downstream denials.
• Documentation gaps requiring callbacks to clinicians, delaying submissions.
• Lost-to-follow-up appeals and timely-filing breaches.
• Status-unknown cases lingering in queues, impacting patient scheduling.
• Channel-selection errors, such as submitting via fax when an electronic option is available.
• Authorization numbers not accurately recorded in the EMR for claim submission.

End-to-End Prior Authorization Automation with Klivira

Klivira's platform automates the entire prior authorization workflow, from initial request submission to status polling, approval/denial routing, and appeal preparation. By integrating directly with EMRs and payer systems, we ensure a seamless and efficient process that minimizes manual intervention and accelerates decision times.

Klivira's Automated Prior Authorization Workflow

• **EMR-side Detection at Order Entry:** Klivira detects PA requirements using CDS Hooks at the point of order entry (src: davinci-crd-ig), preventing missed authorizations.
• **Automated Documentation Assembly:** The platform reads FHIR resources from the EMR to assemble comprehensive documentation packets, utilizing Da Vinci DTR questionnaires where supported (src: davinci-dtr-ig).
• **Payer-Specific Submission Routing:** Requests are routed through optimal channels—Da Vinci PAS API (src: davinci-pas-ig), X12 278 via clearinghouse, provider portal API, or fax fallback—based on payer capability.
• **Real-time Decision Tracking:** Klivira polls payer endpoints or receives webhooks, normalizing status into a uniform workflow state and updating relevant staff via EMR messaging.
• **Approval Write-back & Denial Routing:** Approved authorization numbers are written back to the EMR. Denials are parsed, triggering auto-appeals, human review, or peer-to-peer scheduling.
• **Appeal Automation & Timely-Filing Tracking:** Klivira auto-assembles and tracks appeal packets, enforcing timely-filing windows for each payer.

Adherence to Industry Standards and Regulations

Klivira's prior authorization automation solution is built upon foundational industry standards and regulatory mandates. We leverage HL7 Da Vinci Implementation Guides, including CRD, DTR, and PAS (src: davinci-crd-ig, davinci-dtr-ig, davinci-pas-ig), for interoperable data exchange. Our platform also supports X12 278 for EDI transactions and aligns with the CMS Interoperability and Prior Authorization Final Rule (CMS-0057-F) (src: cms-0057-f) for impacted payers, ensuring robust compliance and efficiency.

Quantifying Impact: Benchmarking PA Automation

The financial and operational benefits of prior authorization automation are well-documented. The CAQH Index (src: caqh-index) consistently highlights the significant cost gap between manual and electronic PA transactions, underscoring the financial argument for automation. Furthermore, the AMA prior-authorization physician survey (src: ama-pa-survey) provides critical clinician perspectives on the burden of manual PA, including its impact on patient care and staff burnout. Klivira helps organizations realize these documented efficiencies, improving both financial health and staff satisfaction.